Failure to Implement Fall Prevention Intervention for High-Risk Resident
Penalty
Summary
A resident with a history of diabetes mellitus, myocardial infarction, depression, frequent falls, and acute ischemic cerebrovascular accident was identified as being at high risk for falls. The resident's comprehensive care plan included an intervention to apply a perimeter mattress to the bed, and this intervention was also documented in the CNA Kardex. However, observations on two separate occasions revealed that the resident was sleeping in a low bed without the required perimeter mattress in place. Staff interviews confirmed that the perimeter mattress was not present, and it was noted that the resident had a room change earlier in the year, after which the mattress was not transferred to the new room. The DON indicated that staff should use the Kardex to ensure current fall interventions are implemented.