Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
The facility failed to implement care plan interventions for a resident identified as being at risk for falls due to multiple factors, including medication side effects, debility, poor oral intake, ataxia, impaired safety awareness, visual impairment, and osteoporosis. The resident's care plan included specific interventions such as keeping the call light within reach and ensuring a fall mat was placed next to the bed. However, during multiple observations, the fall mat was either missing, improperly positioned, or folded against the wall, and the call light was found out of the resident's reach. Staff interviews confirmed that the fall mat was often moved to accommodate the bedside table during meals and was not consistently returned to its proper position afterward. A CNA acknowledged that staff frequently forgot to replace the fall mat after the resident finished eating, resulting in the resident being left without the prescribed fall prevention intervention. These lapses in following the care plan created a potential for unmet care needs for the resident.