Failure to Implement Fall Prevention Interventions as Ordered
Penalty
Summary
Facility staff failed to implement fall and injury prevention interventions as outlined in the medical plan of care for one resident. The resident, who had a history of repeated falls, a recent hip fracture, and was assessed as a high fall risk, had physician orders and a care plan specifying that fall mats should be placed on both sides of the bed. Despite these documented interventions, multiple observations over several days revealed that only one fall mat was consistently present on the right side of the bed, with no mat on the left side as required. Staff interviews confirmed awareness of the orders and care plan, but the intervention was not consistently implemented. The resident was observed in various positions—lying in bed, sitting on the edge of the bed, and in a wheelchair next to the bed—each time with only one fall mat present. There was no evidence of a second mat in the room during these observations. Staff, including a nurse, the unit manager, and the DON, acknowledged that both mats should have been in place according to the care plan and physician's order. The deficiency was further underscored by a recent incident report documenting the resident being found on the floor beside the bed after attempting to get to the bathroom.