Failure to Implement Fall Prevention Measures and Secure Physician Orders for Resident Passes
Penalty
Summary
The facility failed to ensure that two residents were free from accident hazards and that adequate supervision and physician oversight were provided. For one resident, a physician's order dated 10/25/24 required the use of bilateral floor mats due to the resident's risk for falls associated with cognitive loss and lack of safety awareness. However, multiple observations on 5/19/25 revealed that only one floor mat was in place at the bedside, contrary to the physician's order, and this was confirmed by the Director of Staff Development (DSD). For another resident, the facility did not obtain a physician's order prior to the resident going out on pass, as required by the facility's policy. Medical record review showed no such order or care plan allowing the resident to leave the facility unsupervised, despite documentation that the resident had left the facility for extended periods over several months. The Assistant Director of Nursing (ADON) confirmed that the resident frequently went out on pass and that there was no physician's order or care plan in place for these absences.