Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall and accident prevention interventions as outlined in a resident's care plan and physician orders. The resident, who had diagnoses including dementia, major depression, hypertension, and osteoarthritis, was identified as a fall risk and required staff supervision and assistance for all activities of daily living. Despite physician orders and care plan interventions for non-skid strips in front of the recliner, non-slip material in the wheelchair seat, and the use of protective leggings and sleeves, these measures were not in place at the time of observation. The resident's nurse call device was also found out of reach, hanging from a light fixture several feet away from where the resident was seated. The resident experienced an unwitnessed fall from bed, resulting in multiple bruises, abrasions, and a head injury that required emergency department evaluation and treatment. Upon return to the facility, further injuries were noted, including additional bruising and surgical glue applied to wounds. Staff interviews confirmed that required fall prevention interventions were not consistently implemented, and the resident was not wearing the prescribed protective equipment. The lack of adherence to the care plan and physician orders directly contributed to the resident's fall and subsequent injuries.