Failure to Implement Care Planned Fall Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for one resident with a history of falls and multiple medical diagnoses, including metabolic encephalopathy, orthostatic hypotension, chronic atrial fibrillation, and cognitive impairment. The resident was assessed as moderately cognitively impaired and required supervision or assistance with transfers. Despite being care planned for non-skid socks and a non-skid mat on and below the wheelchair pad, the resident was observed wearing socks without non-skid material and without the required non-skid mat in place during multiple observations. The absence of these interventions was confirmed by the facility administrator. The resident experienced two falls in the dining room, one of which was witnessed and triggered an alarm, and another where the resident was found sitting on the floor in front of her wheelchair. The facility's policy requires staff to implement individualized fall prevention interventions based on resident risk, and the administrator acknowledged that the interventions specified in the care plan were not in place at the time of the observations.