Failure to Implement Care Planned Fall Interventions
Penalty
Summary
The facility failed to implement care plan interventions for two residents with a history of falls and major injuries by not placing fall mats at their bedsides as specified in their care plans. For one resident with Alzheimer's disease, muscle weakness, and right-sided hemiplegia, the care plan was revised to include a fall mat after the resident sustained a femur fracture from an unwitnessed fall. Despite this intervention being documented, observations revealed that no fall mat was present at the bedside, and staff interviews confirmed a lack of awareness regarding the requirement for a fall mat. Similarly, another resident with altered mental status, a history of falls, and a subdural bleed had a care plan intervention for a fall mat following a fall resulting in a hip hematoma and brain hemorrhage. Observations on multiple occasions showed that no fall mat was present in the resident's room. Staff members, including nurse aides and nurses, were unaware of the care plan intervention and had not seen a fall mat in the room, despite having access to care cards and care plans that documented this requirement. In both cases, the deficiency was identified through observations, record reviews, and staff interviews, which consistently demonstrated that the care planned intervention of placing fall mats was not implemented. The Director of Nursing confirmed that fall interventions were discussed in meetings and that fall mats should have been placed according to the care plans, but could not explain why the interventions were missed.