Failure to Implement Fall Prevention Care Plan Intervention
Penalty
Summary
The facility failed to implement person-centered care plan interventions for a resident identified as high risk for falls. Observation revealed that the resident's bed was not in the lowest position, contrary to the care plan intervention and a current physician's order, both of which specified that the bed should be kept in the lowest position. The resident, who had diagnoses including congestive heart failure, diabetes, and respiratory failure, was moderately cognitively impaired and had a documented history of two or more falls with injury. During the observation, a QMA confirmed that the bed should not have been left elevated. Review of facility policy indicated that a person-centered care plan should be developed and implemented for every resident.