Failure to Timely Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement timely and appropriate care and services to prevent falls for a resident who was assessed to be at moderate risk. The resident, who had diagnoses including Alzheimer's disease, dementia with behavioral disturbances, and hypertension, was admitted to the facility and assessed for fall risk. Despite being identified as at risk, the resident did not have a fall prevention plan of care or interventions implemented until four days after experiencing a fall in the facility. Record review and staff interviews confirmed that the plan of care and interventions to prevent falls were not put in place until several days after the incident. The facility's own Fall Policy requires that all residents be evaluated for safety risks and that care plans be created and implemented based on individual risk factors to prevent falls. This lapse in timely implementation of fall prevention measures was identified during the investigation of multiple complaints.