Failure to Implement Fall Prevention Plan
Penalty
Summary
The facility failed to implement a person-centered fall and injury prevention plan for Resident 104, who was at risk for falls due to decreased mobility, medications, and a history of falls. The care plan for this resident included the use of bilateral fall mats on the sides of the bed, which were initiated on December 13, 2024. However, observations on December 17, 2024, revealed that the mats were not in place while the resident was in bed, despite the care plan intervention requiring them. The deficiency was confirmed by Employee 5, a Registered Nurse, who acknowledged that the mats were not in place as per the care plan. Additionally, the Director of Nursing confirmed that it was the facility's responsibility to ensure the implementation of interventions developed in each resident's comprehensive person-centered care plan. The failure to implement the care plan intervention for bilateral mats was a lapse in mitigating the resident's risk of injury from falls.
Plan Of Correction
Step 1 - Mats were added to floor bilaterally when resident 104 was in bed. Step 2 - Review of current residents with falls in past 30 days to assure that fall mats on plan of care are in place for resident. DON or designee. Step 3 - Education to nursing personnel on importance of implementation of fall preventatives to prevent injuries on residents with falls are in place as specified on care plans. Staff educator or designee. Step 4 - Random audits for residents with fall risk to assure that care planned items are in place for resident. Weekly times 4 monthly times 2. DON or Designee. Step 5 - Results to QAPI monthly times 2.