Failure to Follow Fall Prevention Interventions
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency occurred when staff failed to follow established interventions to prevent further falls for a resident with Alzheimer's disease. The resident had a documented history of sliding from a dining room chair, after which the care plan was updated to require a Dycem nonslip mat in both the wheelchair and dining room chair. During an observation, the resident was seen being wheeled into the dining room without the required Dycem mat in the wheelchair. A CNA confirmed that the Dycem was not in place because it was soiled and had not been replaced after providing care. The care plan specifically indicated that the Dycem mat should be used to reduce fall risk, but this intervention was not implemented at the time of observation.