Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident identified as being at risk for falls. The resident, who has a history of multiple falls and a range of medical conditions including osteoporosis, dementia, and chronic pain, was observed without fall mats in place, despite these being a specified intervention in her care plan. The absence of fall mats was confirmed during multiple observations and interviews with staff, indicating a lapse in the execution of the care plan. The resident, who has moderate cognitive impairment and uses a wheelchair for mobility, was observed in her room without the prescribed fall mats on the floor. Interviews with the resident and staff, including a CNA and a physical therapist, revealed that the fall mats were not consistently placed as required. The resident confirmed that the mats were only placed in her room for the first time on the day of the survey, despite her care plan indicating their necessity to prevent injury from falls. Staff interviews highlighted a lack of awareness and responsibility regarding the placement of fall mats. The CNA and physical therapist both acknowledged the absence of the mats and the CNA later placed them after being prompted. The Director of Nursing was unaware of the issue until it was brought to her attention during the survey. The facility's policy requires licensed nurses to ensure the application of safety equipment and notify staff of fall risks, but this was not adhered to, resulting in a deficiency in the resident's care.
Plan Of Correction
1. On 2/25/25, resident #7's comprehensive care plan was updated by the Director of Nursing to reflect implemented fall prevention interventions. 2. From 3/20/25 to 3/25/25, the Director of Nursing/Designee completed a review of current facility residents who have experienced a fall to verify the comprehensive care plan reflects the fall prevention interventions implemented. Follow up based on findings. No additional residents were found with interventions not in place as directed by the care plan. 3. On 3/7/25, the Director of Nursing/designee provided education for the interdisciplinary team related to the comprehensive care plan reflecting implemented fall prevention interventions. 4. Director of Nursing/Designee to conduct monitoring of resident comprehensive care plans to verify implemented fall prevention interventions are reflected utilizing the quality-of-care meeting process. Monitoring to be completed weekly x 3 months until substantial compliance or until substantial compliance achieved, then quarterly and as needed. Findings to be reviewed at the monthly QAPI Committee Meeting. Modifications implemented as indicated.