Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement required fall prevention interventions for two residents who were assessed as being at risk for falls. For one resident with diagnoses including unsteadiness, dementia, gait abnormalities, and muscle weakness, clinical records and care plans indicated the need for a chair alarm to be in place and checked every shift. Despite this, observations on multiple occasions revealed that the resident was mobile in a wheelchair without the chair alarm attached, as it was found hanging on the dresser instead. Staff confirmed that the alarm should have been in use and subsequently placed it on the wheelchair after being notified. For another resident, a physician's order required the use of a chair alarm and regular checks for its placement and function. However, repeated observations showed the resident seated in a wheelchair without the alarm in place. Staff interviews confirmed the absence of the alarm during these times. These failures to follow physician orders and care plan interventions for fall prevention were confirmed through staff interviews and review of clinical documentation.
Plan Of Correction
1. Resident 7 and 46 immediately had a chair alarm added the day of the survey. 2. A whole house audit was completed on all residents who are ordered/CP'ed to have a chair alarm to ensure placement in wheelchair, and that the chair alarm is listed in Kardex. 3. All residents who have an order/or CP'ed as a fall intervention will have a chair alarm in place when in a wheelchair. All nursing staff will be educated to ensure the chair alarm is in place when the resident is in a chair. All CNAs will be educated to check Kardex if a chair alarm is needed for safety. 4. Random resident audits will be conducted of residents requiring a chair alarm, daily 4x a week, weekly for 4 weeks, and monthly x2 by the Administrator/designee to ensure the chair alarm is in place and in working order. Results of the audits will be presented at the QAPI committee to ensure ongoing compliance.