Failure to Implement Fall and Injury Prevention Interventions
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision and implementation of safety interventions for multiple residents at high risk for falls and injury. For one resident with metabolic encephalopathy, legal blindness, and a history of falling, the physician ordered floor mats to be placed at the bedside to reduce injury risk. However, observations on multiple occasions revealed that no floor mats were present, and staff confirmed the absence of this intervention despite the resident's high fall risk. The Director of Nursing acknowledged that not providing the prescribed floor mats could potentially result in injury if a fall occurred. Another resident with a history of falling, muscle weakness, and seizures was also ordered to have floor mats on both sides of the bed. Despite this, observations and staff interviews confirmed that no floor mats were present at the bedside. The care plan for this resident included the use of floor mats as a fall prevention measure, but this intervention was not implemented. The Director of Nursing confirmed the omission and recognized the increased risk of injury due to the lack of floor mats. Additionally, a resident with severe cognitive impairment and total dependence on staff had a physician's order and care plan for padded bed rails to prevent injury. During observation, the bed rail padding was found to be ripped, exposing the hard bed rail, and staff acknowledged that this would not protect the resident from injury. Another resident with a history of falls and seizures had incomplete and inaccurate fall risk assessments, with missing documentation of predisposing factors and recent falls. The Director of Nursing confirmed the importance of accurate assessments for effective care. Facility policies reviewed indicated that staff are required to implement and monitor interventions to prevent falls and injuries, but these were not consistently followed.