Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for a resident identified as high risk for falls. The resident, who had a history of hemiplegia and hemiparesis due to a previous stroke, severe cognitive impairment, and was dependent on staff for transfers, was care planned to have a fall mat placed beside the bed whenever in bed. Despite this, multiple observations over two days revealed that the fall mat was not present at the bedside while the resident was in bed. Interviews with staff, including LVNs and CNAs, confirmed that the expectation was for a fall mat to be in place for the resident, and that both nursing and CNA staff were responsible for ensuring interventions were implemented. However, there was confusion among staff regarding who was responsible for placing and documenting the presence of the fall mat. Some staff believed it was the nurses' responsibility, while others thought CNAs should handle it, and documentation practices did not consistently include the fall mat intervention. Further interviews with facility leadership, including the ADON, DON, and Administrator, confirmed that the fall mat should have remained in the resident's room and been in use whenever the resident was in bed. The absence of the fall mat was noted by staff, but no one could account for its removal or ensure its replacement, resulting in the resident being left without a key fall prevention intervention as required by the care plan and facility policy.