Failure to Implement and Document Accident Prevention Interventions
Penalty
Summary
The facility failed to implement and document care plan interventions designed to prevent accidents for three residents identified as being at risk. For two residents with a history of falls, both had physician orders and care plans requiring the use of low beds with bilateral floor mats. However, during multiple observations, these fall mats were not present, despite staff having documented on the Treatment Administration Record (TAR) that the interventions were in place. The absence of the mats was confirmed by the unit nurse manager, and there was no indication that the mats had been removed for care or other reasons during the observed periods. For a third resident assessed as being at risk for elopement, the care plan and orders required the use of a wander guard bracelet and a check of its functionality every shift. While the resident was observed wearing the bracelet and staff documented its placement, there was no documentation of functionality checks after the order for this was discontinued. The unit nurse manager confirmed that both placement and functionality checks should be documented, but only placement was being recorded. These failures demonstrate that the facility did not ensure that care plan interventions to prevent accidents were consistently implemented or documented as required.