Failure to Implement Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to follow care plan interventions designed to prevent further falls for a resident with a history of multiple falls and severe cognitive impairment. The resident, diagnosed with vascular dementia, depressive disorder, and hyperlipidemia, experienced several falls over a period of time, each resulting in updates to the care plan, such as reminders to use the call light, not to ambulate unassisted, and to request assistance with toileting. After a fall, the care plan was updated to include the use of floor mats on both sides of the bed, and staff interviews indicated that these interventions were expected to be in place. Despite these documented interventions, multiple observations revealed that the resident's call light was not consistently within reach and that floor mats were not present on either side of the bed as required by the care plan. Additionally, a review of physician's orders did not show an order for floor mats, despite staff statements to the contrary. These failures to implement and maintain care plan interventions contributed to the ongoing risk of accidents for the resident.