Failure to Implement Physician-Ordered Fall Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement physician-ordered fall prevention interventions for two residents with known fall risks. For one resident with diagnoses including Alzheimer's disease, dementia, and severe cognitive impairment, the care plan and physician orders required specific fall interventions such as non-skid strips to the left side of the bed, non-skid strips in front of the recliner, and dycem to the recliner seat. Observations revealed that these interventions were not in place, and this was confirmed by staff interviews. Another resident, with a history of dementia, seizures, Parkinsonism, and other significant medical conditions, also had physician orders for fall prevention measures. These included dycem to the wheelchair seat, non-skid strips in front of the toilet, and a sign reminding the resident to use the call light. Observations showed that the dycem was missing from the wheelchair, non-skid strips were not present in front of the toilet, and the reminder sign was not visible to the resident. Staff confirmed that these interventions were not implemented as ordered. The facility's policy required that residents be assessed for fall risk and receive care and services according to their risk level. Despite this, the required fall prevention interventions were not consistently provided for residents identified as being at risk for falls, as evidenced by direct observation and staff verification.