Failure to Implement Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in its Fall Prevention and Management Guidelines for two residents identified as high risk for falls. One resident with severely impaired cognition, who had a documented history of falls, was observed in bed without the required floor padding in place. Additionally, this resident was unable to use the standard call light, and when tested, the call light was found to be nonfunctional until it was forcefully reconnected. The care plan for this resident specified the use of floor mats and an alternative call system, but these interventions were not in place at the time of observation. Another resident, also identified as high risk for falls, was observed in bed with the floor padding positioned two feet away from the bed rather than at the bedside as required. The care plan for this resident included the use of floor mats and maintaining the bed in the lowest position, but the observed placement of the floor mat did not align with these interventions. Staff interviews confirmed that both residents were considered high risk for falls and that the specified interventions should have been implemented according to facility policy.