Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that fall prevention interventions were in place for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, peripheral vascular disease, and psychosis. The resident had a documented history of falls and was assessed as being at risk for further falls due to cognitive and physical limitations. The care plan included specific interventions such as keeping the resident in supervised areas, particularly by the nurse's station or in activities when in a wheelchair, and staff education to maintain supervision. Despite these interventions being documented in the care plan and progress notes, the resident was observed in the dining area without supervision on multiple occasions. On one occasion, the resident was found on the floor in the lounge area with a skin tear on his right elbow, and staff confirmed that the required supervision intervention was not in place at the time of the fall. Interviews with facility staff, including a CNA and the DON, verified that the resident had been left unsupervised in the dining area, contrary to the care plan and facility policy. The facility's fall prevention policy required individualized interventions based on assessment and risk factors, which were not consistently implemented for this resident.