Failure to Implement Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement care plan interventions for two residents identified as high risk for falls. One resident, admitted with a history of stroke and anxiety, was assessed as a high fall risk and had a care plan intervention requiring a fall mat to be placed at the bedside when in bed. On multiple occasions, this resident was observed in bed without a fall mat present. Staff interviews confirmed that the care plan was not being followed, and staff were either unaware of the required interventions or acknowledged that they were not implemented. Another resident, admitted with dementia and stroke, also had a care plan indicating a high fall risk and the need for a fall mat when in bed. This resident was observed on two separate occasions sleeping in bed without a fall mat in place. Staff interviews revealed uncertainty or lack of knowledge regarding the resident's fall interventions, and the responsible care manager confirmed the absence of the fall mat and was unable to locate one in the resident's room. These failures resulted in the care plans not being implemented as written.