Failure to Implement Ordered Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as ordered for one resident with a history of multiple falls and moderately impaired cognition. Despite physician orders and care plan interventions specifying that floor mats should be placed on both sides of the resident's bed, observations on multiple occasions revealed that only one floor mat was in use, with the other mat found against the wall and not positioned as required. Staff interviews confirmed awareness of the resident's fall risk and the need for bilateral floor mats, yet the intervention was not consistently implemented. Medical record reviews showed that the resident had experienced multiple falls, leading to specific recommendations and orders for the use of floor mats on both sides of the bed. The facility's policy required staff to identify and implement individualized fall prevention measures, but these were not followed in this case. Both nursing and administrative staff acknowledged that the floor mats should have been in place as ordered, confirming the deficiency in adhering to the prescribed fall prevention interventions.