Failure to Consistently Apply Fall Prevention Interventions
Penalty
Summary
Facility staff failed to consistently implement fall prevention interventions as outlined in the comprehensive care plan for one resident. The resident, who was admitted with diagnoses including liver cancer and major depressive disorder, was identified as being at high risk for falls following a documented fall and a subsequent fall risk evaluation. The care plan specified the use of a bolster on the right side of the bed and a beveled fall mat on the left side of the bed as preventative measures. During an observation, it was noted that neither the bolster nor the fall mat were in place as required by the care plan. This absence was confirmed by an LPN and acknowledged by the Nursing Home Administrator, who confirmed that staff had not consistently followed the care plan interventions for fall safety for this resident. The deficiency was cited under 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.