Failure to Implement Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for two residents identified as being at risk for falls. For one resident with diagnoses including anoxic brain damage, epilepsy, and major depressive disorder, the care plan required that her garbage can be kept within reach to prevent her from attempting to get up unassisted. Observation revealed that the garbage can was placed out of her reach, and both the resident and the Director of Nursing confirmed that this intervention was not being followed, despite its inclusion in the care plan. Another resident, with diagnoses such as adult failure to thrive, dizziness, hypertension, unspecified dementia, and difficulty walking, had a care plan intervention requiring a visual reminder in her room to call for assistance. Observation found that after the resident was moved to a new room, the visual reminder was not transferred with her. An LPN confirmed that the intervention was not in place in the new room and was unaware of the requirement, even though the sign had been present in the resident's previous room. The facility's policy on managing falls requires staff to implement resident-centered fall prevention plans based on individual risk factors. In both cases, the specific interventions designed to mitigate fall risk were not carried out as documented in the residents' care plans, resulting in non-compliance with the facility's own policies and procedures for fall prevention.