Failure to Implement Fall Prevention Interventions as Care Planned
Penalty
Summary
A deficiency was identified when a resident with multiple complex diagnoses, including multiple sclerosis, chronic pain syndrome, anxiety, muscle spasm, tremor, altered mental status, weakness, seizures, and schizophrenia, was not provided with the safety interventions outlined in their care plan. The resident was assessed as being at risk for falls and was dependent on staff for activities of daily living. The care plan specified the use of enabler bars attached to the bed, a body pillow for positioning, and ensuring the call light was within reach. However, during multiple observations, the resident was found in bed without enabler bars or a body pillow, and the call light was not within reach but instead placed on the resident's wheelchair, which was not accessible to the resident. Interviews with CNAs regularly assigned to the resident confirmed that the required interventions, such as the body pillow and enabler bars, were not in place and that staff were unaware of the need for a body pillow. The facility's fall prevention policy required that interventions be provided as needed, but these were not implemented for this resident. The lack of these safety measures constituted a failure to follow the care plan for a resident identified as being at risk for falls.