Failure to Implement Fall Prevention Interventions for Resident with History of Falls
Penalty
Summary
A deficiency occurred when the facility failed to implement care plan interventions to prevent falls for a resident with a history of falls and a recent humerus fracture. The resident's care plan included specific interventions such as being seated in a high visibility area, having a visual cue in the room to remind the resident to use the call light, frequent checks, and not being left alone in the room while up in a wheelchair. However, observations revealed that the resident did not have the required visual cues in the room and was left unsupervised in the room and in the hallway. The resident was also observed in another resident's room without staff supervision. Interviews with multiple CNAs and an LPN indicated a lack of awareness regarding the resident's care plan interventions, including the frequency of checks and the need for visual cues. Staff members were unsure about the resident's fall history and the specific precautions required. The Director of Nursing Services acknowledged that the care plan was not followed, and the required visual cues were not present in the resident's room.