Failure to Implement Fall Prevention Interventions as Care Planned
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions as described in the care plan for a resident with a history of repeated falls, muscle weakness, dementia, and use of anticoagulants. The resident was found on the floor next to his bed with a laceration near his right eye, requiring emergency department treatment and sutures. The facility's investigation revealed that the silent TABs alarm, intended to alert staff when the resident attempted to stand, was left in the resident's recliner instead of being placed on the bed, as required by the care plan. The certified nursing assistant who assisted the resident to bed forgot to move the alarm, resulting in the alarm not being in place at the time of the fall. Further review of the resident's medical record and care plan showed that the resident was care planned to have a silent TABs alarm in both his bed and recliner at all times, with instructions to ensure the alarm was used, plugged in, and functioning when the resident was in either location. However, multiple progress notes documented that the alarm was not consistently placed under the resident at bedtime and was often found in the recliner while the resident was in bed. Staff interviews confirmed that only one alarm was being used and transferred between the bed and chair, rather than having two alarms as specified. Some staff were unaware of the care plan requirements, and others reported that attempts to use two alarms resulted in malfunctions, leading to the removal of the second alarm without alternative interventions being consistently implemented. Observations confirmed that the resident's room did not have two alarms as required, and the STOP, Wait for assistance sign, which was supposed to be in place as an additional intervention, was not visible. Interviews with nursing and administrative staff revealed a lack of awareness regarding the specific fall prevention interventions required for the resident, and documentation of these interventions was inconsistent. The facility's fall prevention policy emphasized the need to identify risk factors and implement interventions before a fall occurs, but these procedures were not followed in this case.