Failure to Timely Implement and Document Fall Prevention Intervention
Penalty
Summary
A resident with diagnoses including altered mental status, muscle weakness, atherosclerotic heart disease, and congestive heart failure was identified as a high fall risk and experienced a fall out of bed. The resident's care plan specified interventions such as ensuring the call bell was within reach, encouraging its use, and placing a floor mat to the left side of the bed. Despite these interventions being documented in the care plan and accident investigation, there was no evidence that a physician's order for the floor mat was obtained or transcribed immediately after the fall. The order for the floor mat was not entered until six days after the incident, and there was no documentation on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) to confirm that nursing staff ensured the mat was in place as required. Interviews with facility staff, including the Director of Nursing Services (DNS) and a regional nurse, confirmed that the expected protocol was to obtain and transcribe a physician's order for the intervention immediately after the fall and to ensure it was reflected on the TAR for staff accountability. The facility's Accident and Incident Investigation policy also required that interventions to prevent further incidents be identified and implemented promptly. The failure to timely implement and document the fall intervention according to the care plan and physician order constituted the deficiency.