Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
Staff failed to implement the individualized care plan for a resident identified as high risk for falls. The resident's care plan, last revised on 4/28/2025, included interventions such as placing frequently used items within reach, using a right leg knee immobilizer, assisting the resident when agitated, providing non-skid socks, placing fall mats, and encouraging the use of the call light. Despite these documented interventions, multiple observations revealed that fall mats were not present next to the resident's bed and non-skid socks were not on the resident during several checks. The resident was observed both lying in bed and sitting up without these safety measures in place. Staff interviews confirmed that the resident was at high risk for falls due to impaired mobility, a history of CVA with hemiparesis, behaviors, and a recent major injury from a fall. The LPN acknowledged the absence of fall mats and non-skid socks, and the Director of Health Services stated that interventions should be visible to CNAs via the care assist dashboard and communicated in reports. However, a CNA reported uncertainty about where to find intervention details and noted that no shift report was conducted, relying instead on nurses to communicate changes. These actions and inactions led to the failure to implement the care plan as written.