Failure to Implement Fall Prevention Care Plan Intervention
Penalty
Summary
The facility failed to implement a fall care plan intervention for one resident who had a history of falls and required assistance with bed mobility and transfers. The resident, who had diagnoses of cerebral infarction and bipolar disorder and demonstrated intact cognition, was observed multiple times without the prescribed fall mat on the left side of the bed, despite the care plan specifying this intervention. The resident reported using a cane for mobility and acknowledged having experienced falls in the facility. During the survey, incident and accident reports for the resident were requested but not provided. Repeated observations confirmed the absence of the fall mat, and the unit manager was unable to explain why the intervention was not in place, suggesting maintenance may have moved it. The facility's policy related to falls was also requested but not received by the end of the survey. The deficiency centers on the facility's failure to ensure that care plan interventions to prevent falls were consistently implemented as documented.