Failure to Consistently Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented for a resident identified as high risk for falls. The resident, who had diagnoses including cognitive impairment, muscle weakness, unsteady gait, and was dependent on staff for mobility and toileting, had a care plan and physician orders specifying multiple fall prevention measures such as a fall mat, hipsters, Dycem on the wheelchair, perimeter mattress, and grippy socks. Despite these interventions being documented, observations revealed that the Dycem was not present on the resident's wheelchair and the fall mat was not in place while the resident was in bed during the day. Staff confirmed these interventions were missing at the time of observation. Additionally, the resident did not recall being educated on the use of the Dycem, and staff interviews indicated that the fall mat was only placed at night. The facility's policy required individualized fall prevention interventions to be implemented and maintained based on assessment and care planning. However, the lack of consistent implementation of these interventions, as observed and confirmed by staff, constituted a failure to provide adequate supervision and maintain an environment free from accident hazards for a resident at high risk for falls.