Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement prescribed fall prevention interventions for a resident with dementia and a history of falls. According to the resident's care plan and incident reports, fall mats were to be placed on both sides of the bed and the bed was to be kept in the lowest position following a fall incident. However, during three out of four days of the survey, observations revealed that only one fall mat was present (on the left side of the bed) and the bed was not in a lowered position as required. These observations were consistent across multiple days and shifts. Interviews with nursing staff and CNAs confirmed that the interventions were known and documented in the resident's profile, and staff acknowledged the importance of following these interventions to prevent further falls. Despite this, the required safety measures were not consistently implemented for the resident, who had diagnoses including dementia with agitation and a history of transient attack. The deficiency was identified through direct observation, record review, and staff interviews, demonstrating a failure to ensure the environment was free from accident hazards and that adequate supervision and interventions were provided.