Failure to Implement Fall Prevention Intervention for High-Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident assessed as high risk for falls, who had a history of falling and severe cognitive impairment. The resident's care plan, revised after a previous fall, required the use of an extended floor mattress to provide protection in the event of a fall. Despite this intervention being documented, the mattress was not placed next to the resident's bed as required. On the date of the incident, staff responded to a bed alarm and found the resident on the floor without the extended mattress in place. Nursing notes indicated the mattress was not used due to concerns that the resident's ambulatory roommate might trip over it. The Director of Nursing confirmed that the care plan intervention should have been implemented, or alternative interventions considered if the mattress was not appropriate. The facility's policy required a resident-centered fall prevention plan for those at risk or with a history of falls.