Failure to Implement Fall Prevention Measures for At-Risk Residents
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for two residents with a history or risk of falls. For one resident with diagnoses including Parkinson's disease, Alzheimer's disease, and other significant conditions, observations revealed that the bed was not kept in the lowest position as required by the care plan, despite the resident being dependent on staff for transfers and bed mobility. Documentation showed that this resident had previously been found on the floor mat next to the bed, and the Director of Nursing confirmed that the bed should have been in the lowest position. For another resident with multiple diagnoses and severe cognitive impairment, observations showed that a floor mat was not present next to the bed while the resident was in bed, contrary to both the care plan and a physician's order. This resident had a documented history of falls from the bed, and the care plan specifically required a floor mat to be in place at all times while the resident was in bed. The Director of Nursing acknowledged that the mat should have been present. These failures demonstrate that the facility did not ensure required fall prevention measures were consistently implemented for residents at risk.