Failure to Properly Implement Fall Prevention Interventions
Penalty
Fine: $21,519
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that the environment remained as free from accident hazards as possible for a resident identified as being at risk for falls. Review of the resident's care plan indicated that fall mats were to be placed on each side of the bed as an intervention, but observations on multiple dates revealed that two fall mats were stacked on one side of the bed instead. The resident had diagnoses including dementia and severe protein-calorie malnutrition. During an interview, the Director of Nursing confirmed that the expectation was for fall mats to be on each side of the bed, in accordance with the care plan.