Failure to Obtain Physician Orders for Fall Prevention Equipment
Penalty
Summary
The facility failed to ensure that two residents' environments were free from accident hazards by not obtaining physician orders for safety equipment used for fall prevention. One resident, who was totally dependent for assistance with transfers, toileting, and bathing and had diagnoses including unsteadiness on feet, dementia, and muscle weakness, was observed with bolster pads on her bed. Review of her records showed no physician orders for the bolster pads, despite her care plan identifying her as high risk for falls and requiring a safe environment. Another resident, also totally dependent for assistance and with similar diagnoses including a history of falls and dementia, was observed with a scoop mattress on her bed. Record review indicated there were no physician orders for the scoop mattress, even though her care plan also identified her as high risk for falls. Interviews with the LVN and DON confirmed that both residents had equipment in use without the required physician orders, and that such equipment could restrict movement and potentially act as a restraint.