Failure to Implement Physician-Ordered Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement fall prevention interventions as ordered by the physician and outlined in the resident's care plan. A resident with diagnoses including type two diabetes mellitus, chronic kidney disease, depression, and spastic hemiplegia was identified as being at risk for falls, with a history of one to two falls in the past three months. The care plan and physician's order specified that a fall mat should be placed on the right side of the resident's bed at all times when the resident was in bed, following a recent fall where the resident rolled out of bed while attempting to reposition himself. Despite these documented interventions, multiple observations on consecutive days revealed that the fall mat was not in place while the resident was in bed. Staff interviews with CNAs and an LPN confirmed that the fall mat was not present, even though they were aware of the care plan and physician's order. Review of the facility's policy on managing falls indicated that staff were expected to implement interventions to prevent falls and minimize complications, but this was not followed in this instance.