Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact but required extensive assistance with daily care and had limited lower extremity range of motion, was not provided with required fall prevention interventions. The resident's care plan indicated a risk for falls and specified that fall mats should be placed at the bedside. Despite this, a nursing note documented that the resident was found lying on the floor on the left side of her bed, after which new interventions were ordered, including placing the bed in the lowest position and using bilateral fall mats. Subsequent observation revealed that the resident was in bed without fall mats on either side, contrary to the care plan and the interventions ordered after the fall. An interview with the Director of Nursing confirmed that the resident should have had bilateral fall mats in place while in bed. This failure to implement and maintain fall prevention interventions resulted in the environment not being as free of accident hazards as possible for the resident.
Plan Of Correction
Resident 9's bilateral fall mats were immediately placed on each side of her bed while she was in bed. Resident 9 was assessed with no noted concerns related to her not having her bilateral fall mats on each side of her bed while she was in bed. Any resident with the fall/injury prevention intervention of fall mat/mats has the ability to be affected by this alleged deficient practice. A whole house audit on residents with the fall/injury prevention intervention of fall mat/mats was completed to ensure the fall mat/mats were correctly in place. Direct care staff, including agency direct care staff, were re-educated on the importance of ensuring fall/injury prevention interventions are in place, including fall mat/mats, as care planned. The Director of Nursing/designee will conduct audits of residents care planned to have a fall mat/fall mats for fall/injury prevention weekly times eight weeks and then monthly times four months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times six months or until substantial compliance is noted.