Failure to Implement Fall Precautions for High-Risk Residents
Penalty
Summary
Facility staff failed to implement fall precautions for two residents identified as high risk for falls. One resident was observed multiple times with her bed not in the lowest position, her call light out of reach, and personal items such as water inaccessible. This resident had a history of multiple falls and her care plan specified that her bed should be kept at the lowest position and her call light within reach. Staff, including an LPN and CNA, confirmed these deficiencies during interviews and observations. The resident was also noted to have a bandaged arm and some confusion, further increasing her vulnerability. Another resident was found sitting on her bed with her feet on the floor, unable to reach her call light, which was tied to a grab bar and hanging to the floor. She expressed the need for assistance to use the bathroom but could not call for help due to the call light's placement. Staff interviews confirmed that fall precautions for residents with a history of falls include keeping beds at the lowest position and ensuring call lights and personal items are within reach. These precautions were not consistently implemented, as evidenced by direct observation and staff acknowledgment.