Failure to Implement Care Planned Fall Prevention Intervention
Penalty
Summary
The facility failed to implement a care planned intervention for a resident with dementia who was identified as being at risk for falls. The resident's comprehensive care plan included the use of a fall mat on the right side of the bed as an intervention to prevent injury from falls. Observations on two separate occasions revealed that the fall mat was not present at the bedside or anywhere in the resident's room, despite the care plan indicating it should be in place. The resident was noted to be severely cognitively impaired, used a wheelchair for mobility, and required varying levels of assistance for bed mobility and transfers, but had not experienced any recent falls. Interviews with staff members, including a nurse aide and a nurse who regularly cared for the resident, confirmed that the fall mat had previously been in place but was not present during their recent shifts. Both staff members acknowledged awareness of the resident's fall risk but did not verify the care plan for ongoing interventions, relying instead on visual cues or familiarity with the resident. The Director of Nursing and the Administrator both confirmed that the fall mat intervention was still current and should have been implemented, but it was not in place at the time of the observations.