Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement a care plan intervention to prevent falls for a resident with conversion disorder, decreased coordination, and impaired lower extremities who used a wheelchair for mobility. The resident had a documented fall, after which the care plan was updated to include keeping the bed in the lowest position and placing a fall mat on the floor. However, multiple observations revealed that the bed was not kept in the lowest position and the fall mat was not present. Staff interviews confirmed that the interventions were not consistently implemented, with one CNA stating the resident preferred the bed at a regular height and that the fall mat was missing. Record reviews and staff interviews further indicated that the required interventions were not documented as declined by the resident, nor was there evidence of consistent monitoring or documentation of the resident's response to the fall prevention measures. The DON confirmed that the expectation was for the bed to be kept in the lowest position and the fall mat to be in place whenever the resident was in bed, and that any resident preference for a different bed height should be documented, which was not done in this case.