Failure to Implement Care Planned Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement a care planned intervention for a resident with a history of falls. The resident, who had diagnoses including Parkinson’s disease, epilepsy, and dementia, was identified as being at risk for falls due to cognitive impairment and impulsive attempts to get up without assistance. The care plan, revised on 5/7/25, specified that a fall mat should be placed at the right side of the resident’s bed. However, during two separate observations on 6/26/25, the fall mat was not present at the designated location while the resident was asleep in bed. The bed was in the lowest position with the left side against the wall, and the head of the bed elevated, but no fall mat was observed on the right side as required by the care plan. Staff interviews revealed that a nurse aide, who was new to the facility, was unaware of the fall mat intervention and had not seen the directive in the care guide. The nurse aide stated that information about fall precautions was typically obtained from the care guide and shift change reports. The nurse on duty could not recall if the fall mat was present earlier that morning and suggested it may have been moved after the resident experienced a seizure the previous night. Both the DON and the Administrator confirmed that all nursing staff are responsible for ensuring fall mats are in place for residents with a history of falls, and that information about such interventions is communicated through care plans, care guides, and shift reports.