Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate fall prevention interventions for residents at risk for falls, resulting in repeated falls for three residents and potential risk for another. Resident R23 was observed sitting at the edge of the bed without proper footwear, despite having a history of falls and being at risk for falls due to poor safety awareness and mild cognitive impairment. The care plan for R23 indicated the need for proper footwear, yet the resident was found without non-skid socks, which are necessary to prevent falls. Resident R43, who also had a history of repeated falls, was observed in a wheelchair without proper footwear. The care plan for R43, who has mild cognitive impairment and difficulty walking, also required well-maintained footwear to prevent falls. Despite this, the resident was not wearing non-skid socks, which are part of the facility's fall prevention policy. Resident R58, with severe cognitive impairment and a history of falls, was observed walking with a walker without the necessary fall prevention measures in place. The facility's policy requires non-skid socks or shoes for residents at risk of falls, but this was not consistently implemented. Additionally, Resident R34, who is at high risk for falls due to cognitive and functional impairments, was observed without non-skid socks, contrary to the care plan's requirements. The facility's failure to ensure that residents at risk for falls were wearing appropriate footwear and receiving adequate supervision contributed to the repeated falls and potential risk for further incidents.