Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans and did not ensure that all required physician orders were in place for two residents reviewed for falls. For one resident with multiple diagnoses including dementia, schizophrenia, and heart failure, the care plan specified interventions such as a non-slip pad on the wheelchair, proper footwear when out of bed, a perimeter mattress, and participation in restorative therapy. While physician orders were present for the perimeter mattress and non-slip pad, there were no orders for proper footwear or restorative therapy, despite these being listed as care plan interventions. Staff interviews confirmed the absence of these orders. For another resident with diagnoses including major depressive disorder, anxiety, and COPD, the care plan required several fall prevention measures, including keeping the telephone cord tucked behind the nightstand. Multiple observations over several days revealed that the telephone cord was not consistently tucked away as required, and this was confirmed by various staff members at the time of each observation. The facility's policy required the interdisciplinary team to identify and implement pertinent interventions based on the resident's fall history, but these interventions were not fully executed as documented.