Failure to Implement Fall Prevention Interventions for Cognitively Impaired Residents
Penalty
Summary
The facility failed to implement required safety interventions for two residents who were identified as being at risk for falls. Both residents had significant medical conditions, including dementia, diabetes, end stage renal disease, heart failure, and convulsions, and were assessed as cognitively impaired and dependent on staff for bed mobility and transfers. Their care plans specifically directed staff to place mats on the floor on both sides of the bed while the residents were in bed to prevent falls. However, clinical record reviews and facility documentation showed multiple incidents where one resident slid out of bed or was found on the floor, and observations confirmed that mats were not in place as required. On the day of the survey, both residents were observed in bed without mats on either side, contrary to their care plan interventions. The Administrator confirmed during an interview that mats should have been present. These findings were based on clinical record review, facility documentation, direct observation, and staff interview, demonstrating a failure to provide adequate supervision and implement safety measures as outlined in the residents' care plans.