Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented and that falls were thoroughly investigated for two residents. For one resident with diagnoses including hypertension, dementia, muscle weakness, COPD, and epilepsy, the care plan required the bed to be placed against the wall, the area to be free of clutter, proper footwear, and the call light within reach. After being found on the floor with complaints of pain, the investigation did not document whether these interventions were in place at the time of the fall. The resident was not wearing footwear, and staff could not confirm if the call light was accessible or if the bed was positioned as required. Another resident, with a history of irregular heartbeat, urinary retention, heart failure, hypertension, and kidney disease, was care planned for fall risk interventions such as nonskid strips, toileting assistance, and use of a reacher. Observation revealed that the reacher was not within the resident's reach, and staff confirmed it should have been accessible to help prevent falls. The facility's fall prevention policy required individualized interventions based on assessments, but these were not consistently implemented or documented for the residents involved.