Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions as outlined in the care plans for three residents with a history of falls. One resident, with repeated falls and fractures, was observed multiple times without a reacher or accessible storage pouch, despite care plan interventions requiring these items to prevent her from leaning forward and falling. She was also left unattended in the dining room, contrary to her care plan, and her wheelchair and bed alarms were installed without documented comprehensive fall risk assessment, education, or informed consent. Another resident, diagnosed with dementia and psychosis, was found to have a regular mattress on his bed instead of the perimeter mattress with bolsters that was ordered as a fall intervention after a previous fall. Observations confirmed the absence of the required mattress, despite its inclusion in the care plan following an interdisciplinary team review. A third resident, with diabetes, weakness, and repeated falls, was found with her call light on the floor and her bed alarm pad unplugged, rendering the alarm nonfunctional. The care plan required the use of a bed alarm and education on call light use, but these interventions were not in place at the time of observation. Facility policies required comprehensive assessment, consideration of alternatives, and informed consent for alarm use, but documentation of these steps was lacking.