Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident, who was at high risk for falls due to lack of coordination and abnormal gait, did not have required fall prevention interventions in place. The resident's care plan, last reviewed on 5/19/25, specified that floor mats should be provided at the bedside as a fall intervention. However, during observations on 6/11/25, no floor mats were present in the resident's room while the resident was in bed. The resident had previously experienced an unwitnessed fall on 5/29/25, as documented in the progress notes and incident report. Staff interviews confirmed that fall interventions are determined after an incident and should be implemented as listed in the care plan, but the required intervention was not in place at the time of observation.