Failure to Implement Fall Prevention Interventions After Initial Fall
Penalty
Summary
The facility failed to provide adequate supervision and implement new fall prevention interventions for a resident with left-sided weakness, muscle wasting, vascular dementia, and a known risk for falls. The resident initially fell from a bed in the low position, and no new interventions were put in place following this incident. Subsequently, the resident experienced another fall from a bed that was not in the low position and was found face down on the floor. As a result of the second fall, the resident required emergency medical treatment for a large scalp laceration with significant bleeding, which was repaired with staples, and was diagnosed with a cervical spine fracture necessitating the use of a cervical collar at all times. This deficiency was identified through record review and interviews with a Nurse Practitioner and staff, and it affected one of three residents reviewed for falls.
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