Failure to Implement Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive care plan for a resident with a history of repeated falls, dementia, schizophrenia, anxiety disorder, and major depressive disorder. The resident was assessed as being at risk for falls and included in the elopement prevention program, with care plan interventions specifying the use of non-skid footwear, frequent rounding to ensure the resident was wearing nonskid socks, supervision during mobility and transfers, and assistance with walking. Despite these documented interventions, the resident experienced multiple falls, both witnessed and unwitnessed, and was observed barefoot with non-skid socks found under the bed rather than being worn. Staff interviews revealed inconsistent implementation of the care plan interventions. Several staff members acknowledged that the resident was a fall risk and should always have non-skid socks on, but also noted that the resident often removed the socks or refused to wear shoes. There was also inconsistency in staff awareness and monitoring, with some staff stating that the resident was checked every 15 minutes or that the room was positioned for better observation, while others admitted that supervision was not constant. The resident's call light was not accessible or understood by the resident, further limiting the ability to request assistance. Facility policies required the development and consistent implementation of individualized care plans and fall prevention measures, including proper footwear and supervision. However, the care plan interventions were not reliably carried out, as evidenced by the resident's repeated falls, lack of non-skid footwear at the time of observation, and staff statements indicating lapses in supervision and intervention. The failure to consistently implement the care plan directly affected the resident's safety and well-being.