Failure to Maintain Fall Prevention Interventions After Room Change
Penalty
Summary
The facility failed to implement and maintain interventions to reduce the risk of accidents for a resident with dementia, Alzheimer's disease, and palliative care needs. After an initial fall, the facility identified the need for a soft touch call light to be kept within the resident's reach and for the resident to be kept under supervision as much as possible. However, when the resident was moved to a new room, the soft touch call light was not transferred with her, resulting in the resident not having access to the intervention that had been put in place to prevent further falls. This oversight led to a second unwitnessed fall, during which the resident attempted to transfer herself and was found on the floor next to her bed. The resident was unable to explain the circumstances of the fall, and it was determined that she did not activate the call light prior to the incident. The deficiency was identified through reviews of incident reports, medical records, and staff interviews, which confirmed that the intervention to prevent falls was not consistently implemented.