Failure to Implement Care Plan Interventions for Fall Prevention
Penalty
Summary
A deficiency occurred when the facility failed to implement care plan interventions for a resident with Alzheimer's Disease and a history of repeated falls. The resident's care plan and physician orders specified the use of two fall mats at the bedside for safety. However, during multiple observations on consecutive days, only one fall mat was present at the resident's bedside. Interviews with facility staff, including an LPN, a CNA, the Assistant Director of Nursing, and the Director of Nursing, confirmed that only one fall mat was in place and that staff were either unaware of the need for a second mat or acknowledged that two mats should have been present according to the care plan and physician orders. The failure to implement the specified intervention was identified for this resident, who had severe cognitive impairment and was at high risk for falls.