Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to provide an environment free from accident hazards by not implementing required fall prevention interventions for one resident. Observations on two separate occasions revealed that the resident was lying in bed without a fall mat placed on the floor as required, and the mat was instead folded and propped against the wall. Additionally, the resident did not have a wedge cushion between his thighs, nor was one present in his room. Multiple staff members, including a CNA, an LPN, and the Director of Nursing, confirmed that the fall mat should have been on the floor to help prevent injury in the event of a fall, and that the wedge cushion was also required but missing. The resident involved had a medical history including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, as well as unspecified convulsions. According to the most recent quarterly MDS assessment, the resident was rarely or never understood, indicating significant communication limitations. The facility's own policy emphasized the importance of making the environment as free from accident hazards as possible and specifically addressed fall prevention, but these interventions were not in place at the time of the observations.