Failure to Implement Care Planned Fall Prevention Interventions
Penalty
Summary
The facility failed to implement a care planned intervention for a resident with a history of falls and major injuries. The resident, who had diagnoses of non-Alzheimer's dementia and Parkinson's disease, was identified as being at risk for falls due to cognitive impairment. After sustaining a right hip fracture from a fall and undergoing surgery, the resident's care plan was revised to include the use of fall mats at the bedside upon return from the hospital. Despite this intervention being documented in the care plan, observations on multiple occasions revealed that fall mats were not placed beside the resident's bed while the resident was in bed. Instead, the fall mats were found folded in the corner of the room. Staff interviews confirmed that the fall mats should have been positioned beside the bed and that it was the responsibility of the nursing staff to ensure this intervention was in place. Both a medication aide and a nurse acknowledged the omission, and the Director of Nursing also stated that fall mats should have been present when the resident was in bed. The lack of implementation of this care planned intervention was directly observed and corroborated by staff, indicating a failure to follow the established care plan for accident prevention.