Failure to Implement Care Plan Intervention for Fall Prevention
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident who was at risk for falls. The resident, who had diagnoses including dementia, chronic obstructive pulmonary disease, polyneuropathy, generalized anxiety disorder, and major depressive disorder, was assessed as having highly impaired vision, severe cognitive impairment, and required assistance with activities of daily living. Following a fall incident in which the resident was found on the floor with an abrasion to the forehead, the care plan was updated to include a floor mat at the bedside as a preventive intervention. Despite this update, multiple observations over several days showed that the floor mat was not present at the resident's bedside as specified in the care plan. Staff interviews indicated uncertainty about responsibility for implementing new interventions after a fall, with the administrator stating it could be any staff member but ultimately the unit manager's responsibility. This failure to implement the care plan intervention as documented placed the resident at risk for safety and injury.