Failure to Implement Care-Plan Fall Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for a resident with multiple medical conditions, including chronic obstructive pulmonary disease, epilepsy, type II diabetes, major depressive disorder, and stage III chronic kidney disease. The resident was identified as being at risk for falls due to generalized weakness, poor balance, decreased strength and endurance, and a need for assistance with activities of daily living. The care plan specified several interventions, including the use of fall mats on both sides of the bed to reduce the risk of injury from falls. During observations conducted at two separate times on the same day, only one fall mat was present on the right side of the resident's bed, with no additional mats found in the room, closet, or bathroom. This was confirmed by a registered nurse, who acknowledged that the resident was care-planned for two fall mats but only had one in place. The lack of full implementation of the care-planned interventions constituted a deficiency in ensuring the area was free from accident hazards and that adequate supervision and assistance were provided to prevent accidents.