Failure to Implement Fall Prevention Interventions and Safe Medication Practices
Penalty
Summary
The facility failed to implement physician-ordered fall prevention interventions and safe medication administration practices for several residents at high risk for accidents. One resident with chronic obstructive pulmonary disease, dementia, and left-sided weakness was identified as high risk for falls and had a physician's order and care plan for a floor mat to be placed on the right side of the bed. However, during observation, no floor mat was present, and the assigned CNA confirmed never seeing one at the bedside. The DON acknowledged that the absence of the floor mat increased the resident's risk for complications from falls. Another resident with Parkinsonism, ataxic gait, and severe cognitive impairment had a physician's order for a personal alarm to be applied while in bed and in a wheelchair, with monitoring every shift. Despite documentation indicating staff monitored the alarm, observation revealed the resident in a wheelchair without any alarm device attached. The activity assistant confirmed the absence of the alarm, and the DON stated that staff did not follow the physician's order, which could result in recurrent falls and injuries. A third resident with encephalopathy, muscle wasting, and dementia, also at high risk for falls, had a physician's order and care plan for a bed alarm following an unwitnessed fall. Observation found the resident asleep in bed without a bed alarm, and the CNA confirmed its absence. The DON stated the importance of the bed alarm for alerting staff to unassisted transfers. Additionally, a nurse was observed leaving medications unattended and out of eyesight at a resident's bedside while retrieving equipment, which the nurse later verified. The DON stated that medications should not be left unattended to prevent unauthorized access and accidental ingestion. Facility policies reviewed supported the need for these interventions and safe practices.