Failure to Provide Prescribed Fall Prevention Device
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction, muscle weakness, and impaired cognition (BIMS score 10/15) was not provided with a required fall intervention. The resident, who required staff assistance with bed mobility and transfers, had experienced multiple falls over a six-month period. The resident's care plan included an intervention for a scoop/perimeter mattress, documented as necessary to prevent further falls. Despite this documented intervention, the resident was observed on two occasions lying on a regular mattress rather than the prescribed scoop/perimeter mattress. Nursing staff and the Director of Nursing confirmed that the resident was supposed to have the specialized mattress in place, but it had not been provided. Facility policy requires that residents at risk for falls receive appropriate interventions and assistive devices to prevent avoidable accidents, but this was not implemented for the resident in question.
Plan Of Correction
ELEMENT 1 It is the practice of the facility to implement fall interventions. R704 scoop/perimeter mattress has been placed on R704 bed, care plan reviewed and updated. ELEMENT 2 Residents that currently reside in the facility that require scoop/perimeter mattress have the potential to be affected by this cited practice. Those residents' charts have been reviewed, and those residents have been assessed to ensure scoop/perimeter mattress is in place. Any deficiency has been immediately updated. ELEMENT 3 The Interdisciplinary Team reviewed the Fall Risk/Injury Prevention policy and deemed it appropriate. Nursing staff have been educated on the Fall Risk/Injury Prevention policy with emphasis on ensuring to implement fall interventions, including scoop/perimeter mattress in a timely manner. ELEMENT 4 The DON/designee will complete random audits on 5 residents a week for 4 weeks, then 5 residents a month for 2 months to ensure fall interventions have been implemented in a timely manner including scoop/perimeter mattress for deficient practice will be corrected/updated immediately. The results will also be taken to the Quality Assurance and performance review meeting. The Administrator is responsible for compliance.