Failure to Implement Care Planned Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain care planned interventions to prevent and mitigate falls for a resident with a history of falls and significant cognitive impairment. The resident, who had diagnoses including atrial fibrillation, stroke, a displaced fracture of the right femur, and senile degeneration of the brain, was care planned to have fall mats on both sides of the bed, the bed in the lowest position, non-skid footwear, and a clutter-free environment. Despite these documented interventions, multiple direct observations revealed that the resident was in bed without fall mats in place on several occasions. Staff members, including a registered nurse and certified nurse aides, did not consistently recognize or implement the requirement for fall mats, and documentation in the electronic health record was not reliably completed to confirm that interventions were in place. Interviews with staff indicated a lack of awareness or understanding of the resident's care plan requirements, with some staff unaware that fall mats were needed and others confirming that documentation of interventions was expected but not always performed. The Director of Nursing acknowledged that the care plan was not being followed and expressed concern about the potential for harm, especially given the resident's recent femur fracture. Review of facility policy confirmed that the nursing team is responsible for communicating and implementing fall prevention interventions for residents with a history of falls.