Failure to Follow Fall Risk Interventions for High-Risk Resident
Penalty
Summary
Staff failed to consistently implement fall risk interventions for a resident identified as being at high risk for falls. The resident had moderate cognitive impairment, required extensive assistance with activities of daily living, and had a history of falls, as well as diagnoses including diabetes mellitus and depression. The care plan specified several interventions, such as keeping the bed in the lowest position, placing a fall mat next to the bed, keeping the door open when the resident was in the room, posting a 'do not fall' sign, and ensuring the call light was within reach. Additionally, staff were to check on the resident and offer bathroom assistance during specific hours. Despite these interventions, multiple falls occurred over several months, each time prompting additional interventions to be added to the care plan. Observations revealed that the resident was found in bed with the door closed, contrary to the care plan instructions. Interviews with nursing staff indicated a lack of awareness of all required interventions, with some staff only aware of the bed and mat requirements and not the need to keep the door open or other measures. The nursing assistant worksheet lacked comprehensive fall interventions, and the facility was unable to provide a fall policy when requested. The DON confirmed that staff were expected to follow care plans at all times, but this was not consistently done for this resident.