Failure to Implement Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement and maintain appropriate fall prevention interventions for a resident with severe cognitive impairment and a history of repeated falls. The resident required assistance with transfers and ambulation, and her care plan included the use of a gait belt for all transfers, a walker within reach for safety, and chair and bed alarms. However, observations revealed that the resident's walker was frequently not within her reach, contrary to the care plan directives. Staff interviews indicated confusion and conflicting instructions from management regarding whether the walker should be left within the resident's reach, with some staff stating they were told not to do so. Additionally, documentation showed that during a witnessed fall, the resident was ambulating with her walker but did not have a gait belt on as required by her care plan. The resident's diagnoses included hypertensive chronic kidney disease, atrial fibrillation, diabetes, and depression, all of which increased her risk for falls and injury. The lack of adherence to the care plan interventions, including the absence of the gait belt and the walker not being within reach, directly contributed to the failure to prevent accidents and ensure adequate supervision.