Failure to Implement and Accurately Document Fall Prevention Interventions
Penalty
Summary
Facility staff failed to provide nursing care within professional standards by not implementing fall prevention interventions as ordered for a resident with a history of falls. The resident's care plan and active physician order required the use of hip protectors while sitting in a wheelchair. Multiple observations on different days showed the resident seated in a wheelchair without hip protectors, despite the active order. Staff interviews confirmed awareness of the order, but staff failed to ensure the intervention was in place. Additionally, documentation inaccuracies were identified. One staff member documented that hip protectors had been placed on the resident in the morning, but this was not observed during subsequent checks. The Director of Nursing confirmed the order for hip protectors was still active and acknowledged the discrepancy between documentation and actual care provided.