Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to follow a post-fall care plan for safety interventions for a resident with dementia, lack of coordination, and Parkinsonism. The resident was identified as a fall/safety risk and the care plan required the bed to be kept at the lowest position and floor pads to be placed on each side of the bed. However, after the resident was found on the floor next to the bed following a fall, observations revealed that only one floor mat was present, and the mat was missing from one side of the bed. Staff interviews indicated a lack of awareness regarding the facility's policy on floor mats and uncertainty about the interventions listed in the care plan. Further review showed that there was no physician's order for the floor mats in the resident's clinical record, despite facility policy requiring such an order to alert staff to implement the intervention. The charge nurse was responsible for ensuring interventions were in place, but the required documentation and implementation were not completed as specified in the care plan and facility policy. The facility's policy also directed that documentation in the medical record should include appropriate interventions to prevent future falls, which was not done in this case.