Failure to Implement Fall Prevention Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for fall safety prevention for two residents identified as being at risk for falls, accidents, and hazards. For one resident, who had a history of falls, dementia, and was receiving hospice care, the care plan required a blue floor mat to be placed next to the bed in the low position. However, multiple observations throughout the day revealed that the floor mat was not in place as required, instead being found leaning against the wall at the end of the bed. There was also no physician's order for a floor mat, despite the care plan directive. The Director of Nursing confirmed that the floor mat should have been in place according to the care plan. For another resident with severe cognitive impairment, Alzheimer's disease, and recent decline on hospice care, the care plan required the call light to be within reach at all times and a floor mat to be placed next to the bed. Observations over several days showed the call light was consistently coiled around the grab bar, out of the resident's reach, and the resident reported calling out for help instead of using the call light. The floor mat was also found folded and pushed away from the bed on one occasion. Staff interviews confirmed that the call light and floor mat were not positioned as required by the care plan, and that residents with limited ability to use call lights should be monitored more frequently. Record reviews indicated both residents had recent falls, and the facility's fall prevention program required individualized interventions to be implemented and monitored for effectiveness. Despite these protocols, the care plan interventions for fall prevention were not consistently followed, as evidenced by the observations and staff interviews.