Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement fall prevention interventions for four residents identified as being at risk for falls. For one resident with a history of falls and a recent wrist fracture, the care plan required nonskid strips at the bedside, but these were not present during observation. The absence of this intervention was confirmed by both facility staff and a regional consultant. This resident's care plan also included other interventions such as ensuring the call light was within reach and the use of appropriate footwear, but the specific intervention added after the most recent fall was not in place. Another resident with dementia and repeated falls was care planned to have a motion sensor night light in the room to provide adequate nighttime lighting. However, during observation, the night light was not present, and this was confirmed by a qualified medication aide. The care plan for this resident had been recently revised following a fall, and the intervention was specifically identified as necessary by the interdisciplinary team. A third resident, who was moderately cognitively impaired and dependent on staff for transfers, was not to be left unattended in a wheelchair in the room, according to the care plan. Despite this, the resident was observed alone in the room in a wheelchair on multiple occasions. Staff confirmed that the resident should not have been left unattended. For a fourth resident with severe cognitive impairment and a history of falls, the care plan required the bed to be in the lowest position and a "call don't fall" sign in the bathroom. Observations revealed the bed was not in the lowest position and the sign was missing. Staff and a family member confirmed the bed was not kept in the lowest position, and documentation showed the sign was not in place.