Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency was identified when staff failed to implement fall prevention interventions for a resident with dementia and diabetes, who had a history of multiple falls. The resident's care plan included specific interventions such as keeping the room door open for visibility, ensuring the wheelchair was at the bedside, and placing the cane near the bed when the resident was in bed. However, observations revealed that the room door was often closed or only partially open, preventing staff from visualizing the resident. Additionally, the resident's wheelchair was repeatedly found across the room under the television, and the cane was placed next to the bathroom wall instead of near the bed. Staff interviews confirmed that the care plan interventions were not being followed. A CNA and an LPN both acknowledged that the wheelchair and cane should have been near the resident's bed for fall prevention, and the Director of Nursing Services confirmed that the interventions were not in place as directed. These failures to implement the care plan placed the resident at risk for injury due to inadequate supervision and lack of access to necessary mobility aids.