Failure to Implement Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement a required intervention to prevent falls for a resident with severe cognitive impairment and a history of falls and fracture. The resident's care plan identified the use of bolsters clipped to the bed as an intervention for positioning and fall prevention. However, on the date of the incident, the resident was found on the floor beside the bed with a 3 cm scratch to the left cheek, and it was documented that the bolsters were not clipped to the bed but were instead loose and laying on the bed. The facility's policy required the interdisciplinary team to investigate and implement appropriate interventions, but the intervention of securing the bolsters was not followed, contributing to the resident's fall.