Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide a safe environment for a resident with dementia, Parkinson's Disease, diabetes mellitus, and a recent history of falls. The resident was identified as high risk for falls and was enrolled in the facility's Falling Star/Super Star Program, which required specific interventions such as keeping the call light within reach and placing a floor mat next to the bed as per physician's orders. Despite these documented interventions, staff did not ensure the call light was accessible when the resident was left alone in the room in a wheelchair, and a floor mat was not placed after the room was deep cleaned, contrary to the physician's order and care plan. Observations and interviews confirmed that the call light was not within the resident's reach and that the required floor mat was missing. Staff members acknowledged these omissions, and the Director of Nursing confirmed that staff were responsible for implementing fall precaution interventions, including those not followed in this instance. Facility policy also required these interventions for residents at high risk for falls, but they were not consistently implemented for this resident.