Failure to Follow Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident with a significant fall history. The resident, who had been admitted after cranial surgery for a brain tumor and had visual loss in one eye, required substantial assistance with mobility and was at high risk for falls. The care plan, updated after a fall, specified the use of bilateral fall mats at the bedside. Despite this, only one fall mat was present during observation, and staff interviews confirmed that the care plan required two mats. The resident herself noted the absence of the second mat and recalled that it had previously been removed. The facility's fall management policy required post-fall evaluations and care plan updates, as well as adherence to interventions listed in the care plan. Multiple falls had occurred for this resident after the care plan was updated to include bilateral fall mats, yet the intervention was not consistently implemented. Staff, including the resident's nurse and the DON, acknowledged the care plan's requirements were not met at the time of observation.