Failure to Implement Care Planned Fall Interventions
Penalty
Summary
The facility failed to implement care planned fall prevention interventions for two residents, resulting in increased risk for falls. For one resident, the care plan required non-skid strips on both sides of the bed, but observations on multiple occasions showed that the strips were not visible or accessible due to the bed's positioning. Additionally, after several falls, including one resulting in major injury, there was no documentation that required interventions such as a tab alarm were in use at the time of the incident, and no new fall prevention measures were added to the care plan following these events. For another resident, the care plan included a fall mat, signage to remind the resident to call for help, and ensuring non-skid footwear was worn. However, observations revealed the absence of a floor mat, call bell, and signage within reach, and the resident was not wearing non-skid socks. Multiple staff members interviewed were unaware of the specific fall prevention interventions outlined in the care plan for this resident. The facility's policy required implementation and consistent application of such interventions, but these were not followed as documented.