Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to implement recommended fall prevention measures for residents identified as high risk for falls. Two residents with multiple medical diagnoses, including repeated falls, unsteadiness, lack of coordination, and dementia, were observed multiple times without the required non-skid mats on their wheelchair seats, despite care plans specifying this intervention. Observations on several occasions showed these residents sitting in their wheelchairs or being assisted by staff without the non-skid mats in place. Staff interviews confirmed that the non-skid mats were not consistently used, and one CNA stated she had never seen a non-skid mat on one resident's wheelchair. The facility's fall incident log documented multiple falls for both residents over a period of several months. The care plans for both residents, which were updated following these incidents, included the use of non-skid mats as a specific intervention to address their high risk for falls due to poor safety awareness, dementia, and other medical conditions. Despite these documented interventions, direct observations and staff interviews revealed that the non-skid mats were not in use at the times observed, indicating a failure to follow the established fall prevention measures for these high-risk residents.