Failure to Implement Physician-Ordered Fall Interventions
Penalty
Summary
The facility failed to implement physician-ordered fall interventions for one resident identified as being at risk for falls. The resident had multiple diagnoses, including generalized muscle weakness, difficulty walking, hypertensive heart disease, and affective mood disorder. The admission nursing assessment indicated the resident was alert and oriented, required one-person assistance for toileting and ambulation with a device, and had several fall risk factors such as muscle weakness, balance deficit, and medication use. Interventions listed in the care plan included encouraging appropriate footwear, maintaining a safe environment, PT/OT evaluation and treatment, providing diversionary activities, and ensuring the call light was within reach. Despite these interventions, a review of the resident's physician orders revealed specific directives for non-skid strips to be placed on the left side of the bed and for brightly colored tape to be applied to the call bell. During an observation with a registered nurse, it was verified that neither the non-skid strips nor the brightly colored tape had been implemented as ordered. This failure to follow physician orders for fall prevention measures constituted the identified deficiency.