Failure to Implement Fall Prevention and Smoking Safety Interventions
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions for multiple residents who had documented falls. Despite having a Fall Prevention Program that required individualized assessment and intervention, several residents experienced repeated falls, and the interventions documented in their care plans and fall reports were not in place during a subsequent survey. For example, one resident had multiple falls in the bathroom and bedroom, with interventions such as non-skid strips and non-adhesive pads documented but not present during inspection. Another resident who fell in front of a recliner did not have the prescribed non-skid strips in place, and a third resident who fell out of bed did not have the required perimeter mattress in use. The Director of Nursing confirmed during the tour that these interventions were missing and was unable to explain why they had not been implemented. Additionally, the facility failed to accurately assess and enforce smoking safety policies for a resident with significant psychiatric diagnoses, including schizoaffective disorder, bipolar disorder, depression, and a history of suicidal ideation. The resident had multiple documented incidents of possessing and using prohibited smoking materials, such as marijuana vapes, nicotine vape juice, lighters, and edibles, in violation of the facility's smoking policy. Despite these incidents, the resident's Smoking and Safety Assessment was not updated to reflect noncompliance, and there was no documentation that the facility followed its own policy to ensure the resident's safety regarding smoking materials. These deficiencies were identified through record review, staff interviews, and direct observation, which confirmed that required safety interventions and policy enforcement were not consistently carried out for residents at risk of falls and those with smoking-related safety concerns.