Failure to Implement Fall and Dietary Interventions
Penalty
Summary
The facility failed to implement identified interventions for residents at risk for injuries related to falls. Resident #93, who was cognitively intact, had a care plan that included the use of a fall mat next to the bed while in bed. However, observations revealed that the fall mat was consistently rolled up and placed between the wall and the dresser, rather than being positioned on the floor as required. Interviews with staff and the resident confirmed that the fall mat was not consistently placed as per the care plan. Similarly, Resident #94, who had severely impaired cognition, was also at risk for falls and had a physician's order for a fall mat to be placed at the bedside while in bed. Observations showed that the fall mat was not in place and was instead leaning against the wall. Staff interviews confirmed that the fall mat should have been placed next to the bed as an intervention to prevent falls. Additionally, the facility failed to ensure that thin liquids were not accessible to Resident #22, who required nectar-thickened liquids due to dysphasia and severely impaired cognition. Observations revealed that a water bottle containing thin liquids was accessible on the resident's nightstand, contrary to the prescribed dietary intervention. Staff interviews confirmed that thin liquids should not have been accessible to the resident, indicating a failure to adhere to the prescribed dietary plan.