Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement fall prevention interventions as outlined in the comprehensive care plan for a resident with significant fall risk factors. The resident had a history of falls, severe cognitive impairment, right-sided hemiparesis, and was dependent on staff for transfers. The care plan required a fall mattress to be placed next to the bed at all times when the resident was in bed, as he had previously fallen out of bed. Despite this, multiple staff members, including an LPN and a nursing assistant, entered and exited the resident's room without ensuring the fall mattress was in place after it had been moved. The mattress remained out of position for an extended period while the resident was in bed, contrary to the care plan directives. Observations confirmed that the fall mattress was not replaced after staff completed their tasks, and interviews with staff and the DON verified that the intervention should have been in place to prevent injury. The facility's policy required staff to implement and monitor resident-specific fall interventions, but this was not followed in this instance. The deficiency was identified through direct observation, staff interviews, and review of the resident's care plan and facility policy.