Failure to Implement Comprehensive Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with a history of multiple falls and severe cognitive impairment. The resident, admitted with chronic atrial fibrillation, multiple fractures, osteoporosis, dementia, and adult failure to thrive, experienced several falls over a period of months. The care plan included interventions such as keeping the resident in high-visibility areas when in a wheelchair, ensuring the resident was up in a wheelchair during daytime hours, and placing non-skid strips at the bedside. However, repeated observations revealed that non-skid strips were not present at the resident's bedside on multiple occasions, despite this being a documented intervention. Additionally, the resident was observed left unsupervised in both his room and in the hallway, contrary to the care plan's directive for high-visibility supervision. Interviews with staff indicated a lack of awareness and implementation of the care plan interventions. A CNA was unaware that non-skid strips were required, and the RN confirmed that this intervention was not included in the care guide used by staff. The DON acknowledged that non-skid strips were not in place until prompted by surveyor questions. The resident's family member expressed concern about the frequency of falls, and staff interviews confirmed that the care plan was not consistently followed, particularly regarding supervision and environmental safety measures.