Failure to Implement Fall Prevention Interventions as Indicated
Penalty
Summary
The facility failed to implement fall prevention interventions as indicated for a resident with multiple medical conditions, including severe cognitive impairment, mobility limitations, and a history of falls. Despite documented care plans and assessments identifying the need for specific interventions such as the use of hipsters, toileting and repositioning every two hours, and keeping the call light within reach, these measures were not consistently followed. Observation revealed that the resident was not wearing hipsters as required, and this was confirmed by an LPN at the time of observation. The resident had experienced multiple falls while attempting to ambulate to the restroom, and each incident resulted in updates to the care plan with new interventions. However, the lack of adherence to these interventions, specifically the failure to apply hipsters, demonstrated a lapse in the facility's responsibility to provide adequate supervision and implement individualized fall prevention strategies as outlined in their own policy.