Failure to Implement Care Plan Fall Interventions for At-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with a history of falls and multiple diagnoses, including traumatic brain injury, muscle weakness, and dementia, was not provided with a fall intervention as specified in their care plan. The care plan, updated to include a bed mat as a fall prevention measure, was not implemented, as the resident was repeatedly observed without a mat beside the bed over several days. The resident's clinical record indicated moderate cognitive impairment and a recent history of two or more falls without injury. Interviews with nursing staff revealed a lack of awareness regarding the required fall intervention, with one LPN unsure if a mat was needed and not referencing the care plan or Kardex for guidance. The Director of Nursing Services confirmed that fall interventions should be accessible in the care plan or Kardex. The facility's fall prevention policy required additional interventions based on assessment, but the specified intervention of a bed mat was not in place for the resident at risk.