Failure to Implement Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to ensure that fall prevention interventions were implemented as ordered for two residents identified as being at risk for falls. For one resident with diagnoses including peripheral vascular disease, deep vein thrombosis, and unsteadiness, physician orders and the care plan required the bed to be in the lowest position when occupied. Despite these orders, multiple observations over several days found the resident in bed with the bed not in the lowest position. An LPN confirmed that the bed was not in compliance with the physician's order during these observations. For another resident with a history of pathological fracture, vascular dementia, and muscle weakness, the care plan included an intervention to post a reminder sign in the room to prompt the resident to call for assistance. Observations on two separate occasions revealed that no such sign was present in the resident's room. An RN confirmed that the required sign was not posted as specified in the care plan. The facility's policy required staff to implement individualized fall prevention plans for residents at risk, but these interventions were not in place for the two residents reviewed.