Failure to Document Fall and Implement Ordered Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough fall investigation and proper documentation for one resident and failure to implement ordered fall-prevention interventions for another. One resident with Lewy Bodies dementia, Alzheimer’s disease, chronic pain syndrome, severe cognitive impairment, and a documented high risk for falls had a care plan that included analyzing previous falls, keeping the call light accessible, and assessing factors leading to any fall with notification of the physician and family. Video surveillance showed this resident on the floor in front of her door at 2:08 A.M., appearing to have fallen, with two staff members responding. However, this fall was not documented anywhere in the medical record, and the resident’s family confirmed they were not notified of the fall. The second resident, admitted with Alzheimer’s disease, essential hypertension, generalized anxiety disorder, severe cognitive impairment, and a high fall risk, had a physician’s order and care plan intervention for non-slip gripper socks to be worn while in bed as tolerated. This resident had sustained multiple falls in the weeks prior. During observation, the resident was lying in bed with both feet uncovered, and non-slip socks were not on the resident, on the bed, or on the floor near the bed. A CNA confirmed that the resident was supposed to have bilateral gripper socks on while in bed and that they were not present, despite the resident’s history of falls and the existing order and care plan intervention. The facility’s falls policy required monitoring and documenting residents’ responses to fall interventions and re-evaluating interventions if falls continued.
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