Failure to Implement Fall Prevention Intervention for At-Risk Resident
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in its Fall Prevention Program for one resident identified as at risk for falls. The program requires individualized assessment and the use of appropriate interventions, including assistive devices, for residents at risk. Documentation showed that a non-slip material was to be added to the resident's wheelchair as a fall prevention measure. However, during observation, the resident was seen propelling herself in the dining room without the required non-slip material in her wheelchair. This was confirmed by a Licensed Practical Nurse present at the time. Additionally, nurse's notes indicated that the resident had previously been found sitting half-upright near her bed, further indicating a risk for falls.