Failure to Implement Fall Prevention Intervention as Ordered
Penalty
Summary
The facility failed to implement a physician's order to place a floor mat on the left side of a resident's bed, as part of fall prevention interventions. During an initial tour, the resident was observed in bed with the bed in the lowest position, but no floor mat was present on the left side. The resident's care plan, physician's order, and facility policy all indicated the need for a floor mat due to the resident's high risk for falls and tendency to lean to the left. The resident had severe cognitive impairment and was unable to make decisions, further emphasizing the need for adherence to safety interventions. Interviews with facility staff, including an LVN and the DON, confirmed awareness of the physician's order and the absence of the floor mat at the time of observation. The LVN acknowledged that the floor mat should have been in place for safety reasons, and the DON verified the findings. The failure to follow the prescribed intervention constituted a deficiency in providing necessary care and services to prevent accidents.