Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to follow established interventions to prevent falls for a resident with significant risk factors. The resident had a history of hemiplegia, hemiparesis following a stroke, dementia, Alzheimer's disease, unsteadiness, a femur fracture, and osteoporosis, and was assessed as having memory problems, severely impaired decision-making, daily wandering, and required assistance with activities of daily living. The care plan and physician's orders required the use of a weight-based alarm mat to be in place on the resident's wheelchair to alert staff if the resident attempted to get up, due to impulsive behaviors and high fall risk. On the date of the incident, the resident was found on the floor after having been last seen sitting in a wheelchair in the lobby. Documentation and staff interviews confirmed that the weight-based alarm mat was not in place on the wheelchair at the time of the fall, contrary to the care plan and physician's orders. Staff, including the LPN and CNA, acknowledged that the alarm mat should have been in use and demonstrated that the alarm would have sounded if the resident had leaned forward as described in the incident. The DON confirmed that fall prevention devices should be in place as ordered.