Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency was identified when the facility failed to implement fall prevention interventions for a resident with multiple diagnoses, including chronic obstructive pulmonary disease, schizophrenia, dementia, and impaired mobility. The resident was assessed as cognitively impaired and required maximal to total assistance with activities of daily living. The care plan included specific fall prevention measures such as placing a floor mat on the open side of the bed, ensuring the call light and personal items were within reach, and providing close staff supervision. During an observation, the resident was found in bed without a call light or personal items within reach, and no floor mat was present next to the bed. The nurse supervisor confirmed these findings. Review of the facility's call light policy indicated that staff were required to ensure the call light was accessible to residents before leaving the room. The failure to follow these interventions and policies led to the cited deficiency.