Failure to Implement Fall Prevention Interventions as Ordered
Penalty
Summary
The facility failed to implement fall prevention interventions in accordance with physician orders for a resident with multiple complex medical diagnoses, including encephalopathy, acute respiratory failure with hypoxia, congestive heart failure, acute kidney failure, and chronic obstructive pulmonary disease. The resident was assessed as having severely impaired cognition and required varying levels of assistance for activities of daily living. The care plan identified the resident as being at risk for falls and included interventions such as encouraging slow standing, ensuring the floor was free of hazards, keeping items within reach, providing non-skid footwear, and assisting with transfers as needed. Despite these interventions, the resident experienced two falls on the same day. After the first fall, new interventions, including placing the bed in the lowest position and adding a mat next to the bed, were documented. However, during the second fall later that day, it was observed that fall mats were not present on the floor as ordered. Staff interviews confirmed that fall mats were not in place at the time of the second fall, and documentation showed that the intervention was not consistently implemented. The facility's policy required updating the care plan and communicating new interventions during shift reports, but these steps were not effectively carried out.