Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned interventions to prevent falls for a resident with cognitive impairment and a history of falls. The resident, diagnosed with fibromyalgia and admitted in January 2025, had multiple documented falls and was care planned to have a 'call don't fall' sign within eyesight and to use a front wheel walker (FWW) for ambulation. However, observations over several days revealed that the resident did not have the required sign posted in the room and was not provided with a FWW. Instead, the resident was seen using a wheelchair to ambulate to the restroom and reported not being offered a FWW. Interviews with staff confirmed the absence of the sign and the FWW, with multiple CNAs and an LPN stating that the resident was not given a FWW and that the sign was not present in the room. The Resident Care Manager acknowledged that the care plan required these interventions but was unaware that the resident was using the wheelchair for ambulation instead. These failures to follow the care plan placed the resident at risk for further falls and injury.