Failure to Implement Fall Prevention Interventions for At-Risk Resident
Penalty
Summary
A deficiency was identified when a resident at risk for falls did not have appropriate fall prevention interventions in place as outlined in their care plan. The resident, who had a history of acute respiratory failure, congestive heart failure, cardiomegaly, atrial fibrillation, and a previous hemorrhagic stroke, was assessed as being at risk for falls due to poor mobility, a history of stroke, and general weakness. The Minimum Data Set assessment indicated the resident required staff assistance for transfers, ambulation, and personal hygiene, and had impaired cognition. Despite these risk factors, the resident was found on the floor after attempting to self-transfer from a recliner while wearing regular socks instead of the required non-skid footwear or shoes. Staff interview confirmed that the resident was not wearing non-skid socks or shoes at the time of the fall, contrary to the interventions specified in the resident's fall care plan. The facility's fall management policy requires maintaining a hazard-free environment and implementing preventative measures for residents at risk of falling. The failure to ensure the resident was provided with non-skid footwear as an intervention contributed to the fall incident.