Failure to Maintain Fall Prevention Interventions for Residents at Risk
Penalty
Summary
The facility failed to ensure that two residents at risk for falls had appropriate fall prevention interventions in place, specifically the use of fall mats and maintaining beds in the lowest possible position when residents were in bed and unattended. For one resident with a history of falls, moderate cognitive impairment, and significant physical assistance needs, observations revealed that fall mats were not consistently placed on the floor as required, and the bed was not always kept in the lowest position. The resident confirmed experiencing two falls since admission, one from the bed, and noted that the fall mats were only sometimes in place. Staff interviews corroborated that the mats should have been on the floor and the bed in the lowest position whenever the resident was unattended, but this was not consistently done. Additionally, the care plan for this resident did not initially include specific interventions such as the use of fall mats and keeping the bed in the lowest position, despite the resident's documented fall risk and previous falls. Progress notes indicated that after the resident's fall, staff documented the use of fall mats and bed positioning, but these interventions were not reflected in the care plan until after the deficiency was identified. Observations on multiple occasions showed the fall mats leaning against the wall and the bed elevated above the lowest setting while the resident was unattended. A second resident, also at risk for falls due to severe cognitive impairment and requiring substantial assistance, was observed with fall mats in place but with the bed not consistently maintained in the lowest position when unattended. Staff interviews confirmed the expectation that the bed should be kept in the lowest position for residents with fall mats, but this was not always followed. The care plan for this resident did include the use of fall mats and low bed positioning, but observations showed lapses in maintaining the bed at the lowest height. These failures were contrary to the facility's fall management policy and federal regulations requiring the environment to be free from accident hazards and for residents to receive adequate supervision and assistive devices to prevent accidents.