Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure safety interventions were in place for Resident 45, who was at risk for falls. Resident 45 had medical conditions including diabetes, muscle weakness, dizziness, and giddiness, and required staff assistance for bed mobility and transfers. The care plan identified the resident as being at risk for falls due to impaired mobility, with an intervention to place floor mats on both sides of the bed while the resident was in bed. However, during multiple observations, the floor mats were not in place while the resident was in bed. This was confirmed by the Director of Nursing during an interview.
Plan Of Correction
Part 1. Resident #45 was immediately provided with fall mats as care planned. Part 2. Like residents with care planned fall mats were audited to ensure the fall mats were properly in place. Part 3. Facility staff education provided to ensure care planned fall mats are in place as indicated. Part 4. Residents identified as being care planned to use fall mats will be audited to ensure placement as indicated. Auditing will be completed weekly X 4 weeks, bi-weekly X 4 weeks and monthly X 1 month. 5. Date of compliance is May 13, 2025.