Failure to Follow Fall Prevention Care Plan for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement required safety interventions for a resident at risk for falls. Clinical record review showed that the resident had neurocognitive disorder with Lewy body dementia and seizures, was cognitively impaired, and required the assistance of two staff members for care due to fall risk and resistance to care. Despite these documented needs, a nurse aide provided care alone and did not position the resident properly in bed, resulting in the resident jerking her legs and rolling out of bed. Facility investigation and staff interviews confirmed that only one staff member was present during care, contrary to the resident's care plan, and the Director of Nursing acknowledged that the care plan was not followed.