Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not consistently implementing fall prevention interventions as outlined in the care plans for three residents. One resident with severe cognitive impairment, a history of falls, and dependence on staff for mobility and ADLs was observed multiple times without the required anti-rollback device and Dycem mat on her wheelchair, despite these being documented interventions following previous falls. Staff interviews revealed that the resident's wheelchair may have been switched without ensuring the interventions were reapplied, and staff were expected to review and implement all care plan interventions. Another resident, also with severe cognitive impairment and total dependence on staff, was care planned to have a fall mat next to his bed due to a high risk of falls. However, on several occasions, the fall mat was observed propped against the wall rather than placed on the floor as required. Staff confirmed that the mat should have been in place and acknowledged the expectation to follow care plan interventions for fall prevention. A third resident, with multiple diagnoses including dementia, muscle weakness, and a history of falls, was care planned to have her bed in the lowest position and her call light within reach. On repeated observations, her bed was found elevated and not in the low position as required. Staff interviews confirmed that all nursing staff had access to care plans and were expected to ensure interventions were in place. The facility's own Fall Management System policy required the environment to be as free of accident hazards as possible and for interventions to be implemented to prevent falls, but these were not consistently followed for the residents reviewed.