Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident with a history of falls, specifically neglecting to ensure that floor mats were placed on both sides of the bed as directed in the care plan. The resident, who had diagnoses including dementia, hemiplegia and hemiparesis following a stroke, muscle weakness, and difficulty walking, was identified as high risk for falls. The care plan included several interventions such as keeping the bed in a low position, using body pillows, and placing floor mats on each side of the bed. Despite these directives, documentation and staff interviews revealed that the floor mats were not in place at the time of a fall incident. On one occasion, the resident was found on the floor mat after a fall, but on a subsequent occasion, the resident was found on the floor without documentation that the mats were in place. The nurse's notes and incident reports failed to confirm the presence of the mats during the second fall, and staff interviews confirmed that the mats were not in place at that time. The DON acknowledged that it was staff responsibility to implement all care plan interventions and was not aware that the mats were missing during the incident investigation. Facility policies required comprehensive, person-centered care plans with measurable objectives and timely implementation, but these were not followed in this case.