Failure to Ensure Fall Prevention Interventions Were Consistently Implemented
Penalty
Summary
A deficiency occurred when the facility failed to ensure that fall prevention interventions were consistently in place for a resident with a significant history of falls and multiple risk factors. The resident, who was severely cognitively impaired and required substantial assistance with activities of daily living, had diagnoses including a displaced fracture of the left femur, emphysema, dementia, and tremors. The care plan specified the use of bed and chair alarms at all times, as well as other interventions such as scheduled toileting, non-skid socks, and increased supervision. Despite these documented interventions, the resident experienced an unwitnessed fall in her room after attempting to get out of bed without assistance. At the time of the fall, the bed alarm was not in place as required by the physician's order and care plan. Staff interviews confirmed that the alarm was not always in use, and the Director of Nursing acknowledged that the bed alarm was not in place at the time of the incident. The incident report and progress notes documented that the resident was found on the floor with a laceration to her finger and was incontinent at the time of the fall. The facility did not provide a fall prevention policy when requested. The failure to ensure that required fall prevention interventions were in place directly contributed to the resident's fall.