Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident identified as high risk for falls. The resident, who was confused, non-interviewable, and had a history of falls, was observed without required fall prevention devices such as floor mats, a non-slip device (dycem), and a specialized positioning wheelchair cushion, despite these being listed on her care plan and Caregiver communication sheet. Staff confirmed that the resident had recently slid from her wheelchair and that interventions were posted to inform staff, but these interventions were not in place during observation. The resident's care plan, last revised earlier in the month, included multiple active interventions specifically to address her high fall risk due to limited mobility, general weakness, dementia with behaviors, and a history of falls. Staff interviews revealed that the resident required constant supervision and redirection due to frequent unsafe movements in her wheelchair, and that she had experienced two recent falls in the dining room while under staff supervision. Incident reports indicated that the root causes of these falls were related to poor positioning and unsafe leaning in the wheelchair. Although the facility's policy required evaluation and modification of care plans after each fall, the required interventions were not consistently implemented, as evidenced by the absence of fall prevention devices during the surveyor's observation.