Failure to Implement Fall Prevention Interventions for Residents with History of Falls
Penalty
Summary
The facility failed to ensure that residents with a history of falls and injuries had appropriate fall prevention interventions in place. One resident, who had diagnoses including Alzheimer's disease and dementia, was observed twice with her call light not within reach, despite her care plan specifying that the call light and personal items should be accessible. This resident had recently fallen while attempting to reach for something from her nightstand, resulting in visible injuries, and was unable to locate her call light during both observations. Documentation confirmed her cognitive intactness and dependence on staff for mobility and transfers. Another resident, with a history of a left humerus fracture and other medical conditions, was observed without required non-skid strips near his recliner and without a Dycem mat in his wheelchair, as ordered in his care plan. The resident had recently fallen while trying to pull up his pants from the recliner, resulting in a fracture and hospitalization. Observations confirmed the absence of these fall prevention interventions, and staff interviews indicated that the resident was frequently noncompliant with the Dycem and that the recliner may have been moved, leading to the non-skid strips not being in the correct location.