Failure to Implement Fall Prevention Interventions as Planned
Penalty
Summary
The facility failed to implement planned fall prevention interventions for a resident with a history of falls, dementia, anxiety, contracture of the left thigh muscle, and a previous right femur fracture. The resident's care plan included keeping the bed in the lowest position when in bed and placing signage in a visible location to remind the resident to ask for assistance. Multiple observations over several days revealed that the resident's bed was not kept in the lowest position and there was no signage present in the room as required by the care plan. Staff interviews confirmed that these interventions were not consistently in place. The resident was transferred to the hospital after admitting to staff that she had fallen from her wheelchair several days prior, resulting in a right femur fracture. The facility's process for ensuring care plan interventions were in place was informal and not documented, relying on staff observations and verbal communication. The DON stated that direct care staff learned about interventions through the Kardex, Grand Rounds, or verbal reports, but there was no evidence that the required interventions were consistently implemented for this resident.