Failure to Implement Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions for two residents identified as being at risk for falls. For one resident with severe cognitive impairment, muscle weakness, and a history of falls, the care plan included a perimeter mattress and a reacher, but upon observation, neither was present in the resident's room after a room change. The CNA was unaware of the reacher, and the DON confirmed the absence of both the perimeter mattress and reacher. This resident had previously experienced an unwitnessed fall, and the fall investigation noted improper footwear at the time of the incident. For another resident with moderate cognitive impairment, limited mobility, and a history of falls, the care plan required a 'call before you fall' sign and ensuring the call light was within reach. After a fall during a self-transfer, the investigation recommended adding the sign to the resident's room. However, observation revealed that the sign was not present, and the CNA was unaware of any fall prevention interventions for this resident. The DON confirmed the absence of the required reminder sign. The facility's policy required identification of residents at risk for falls and the implementation of care plan interventions, which were not consistently in place for these residents.