Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement an individualized care plan for fall prevention for one resident. According to facility policy, safety alarms are to be used for residents with a history of unassisted transfers when staff assistance is necessary for safety. The resident in question was alert and oriented, required maximum assistance for daily care, had a diagnosis of hip fracture, and was assessed to require a motion sensor alarm at the foot of the bed at all times when in bed. However, a nursing note documented that the resident was found on the floor, and a witness statement confirmed that the alarm was not present at the time of the incident. The Director of Nursing verified that the alarm was not in place and activated as required by the care plan.