Failure to Provide Fall Prevention Measures for High-Risk Resident
Penalty
Summary
A deficiency was identified when the facility failed to implement appropriate safety measures for a resident with multiple risk factors for falls, including muscle weakness, epilepsy, unsteadiness on feet, and severe cognitive impairment. The resident was assessed as a high fall risk, with a history of falls documented in progress notes, including incidents where the resident was found on the floor or observed attempting to get out of bed or a chair. Despite these risk factors and repeated fall incidents, observations revealed that no fall mats were placed around the resident's bed or chair during multiple checks, and the bed was only placed in the lowest position. Interviews with staff confirmed that the resident was capable of moving in bed and often attempted to get out of bed or the geriatric chair. Staff reported they were not instructed to use fall mats, and the DON was unaware that fall mats were not in place, despite knowing the resident was a high fall risk. These actions and inactions resulted in the facility failing to ensure adequate supervision and safety measures to prevent accidents for this resident.