Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, unsteadiness on feet, and disorientation. The care plan specified the use of non-skid material under and on top of the wheelchair cushion, as well as non-skid strips on the closet side of the bed. However, during observation, these interventions were not in place; there were no non-skid strips on the closet side of the bed and no non-skid material in the resident's Broda chair. This was confirmed by a CNA during an interview. The facility's policy required staff to identify and implement interventions based on the resident's specific risks to prevent falls, but these measures were not followed for this resident.