Failure to Apply Physician-Ordered Non-Skid Strips for Fall Prevention
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not ensuring the consistent application of physician-ordered preventative safety measures for a resident. The resident, who had diagnoses including dementia and Parkinson's disease and was assessed as having moderately impaired cognition, had a physician's order for non-skid strips to be placed on the floor on the door side of the bed due to a history of multiple falls and an identified risk for falls. The resident's care plan also included this intervention. During observations on two separate occasions, it was noted that the non-skid strips were not present on the floor as ordered. This absence was confirmed by a Registered Nurse Supervisor. Further, interviews with the Regional Nurse Consultant and Nursing Home Administrator confirmed that staff had not consistently followed the physician's order for the application of non-skid strips for the resident's safety.