Failure to Consistently Implement Fall Prevention Measures
Penalty
Summary
A resident with severe cognitive impairment, generalized muscle weakness, difficulty walking, and a history of falls was identified as being at high risk for falls. The resident's care plan included specific fall prevention interventions such as bilateral fall mats, triangular wedges on both sides of the bed, a tab alarm while in bed, and maintaining the bed in a low position. Physician's orders also required triangular wedges to be positioned at the upper bilateral bed rails while the resident was in bed. Despite these interventions, the resident experienced an unwitnessed fall from bed, resulting in a minor injury. Review of the incident revealed that at the time of the fall, the left-side bed wedge was not in place as required and was found on the window frame, while the right-side wedge was in place. Additionally, the bed alarm was nonfunctional, and it was noted that the resident had a known history of disabling the alarm. The facility's investigation concluded that the fall occurred due to failure to follow the resident's plan of care, specifically the improper placement of the bed wedge and the nonfunctional bed alarm.