Failure to Implement Fall Prevention Intervention as Outlined in Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive, person-centered care plan for a resident identified as high risk for falls. The resident, a male with diagnoses including unspecified Parkinsonism, involuntary abnormal movements, cognitive communication problems, and prostate cancer, was dependent on staff for activities of daily living and had a history of falls. His care plan, revised in April, specified the use of a floor mat as a fall prevention intervention. On the date of the incident, the resident was observed in bed without the required floor mat in place, despite being awake and attempting to climb out of bed. Staff interviews revealed that the floor mat was not present because it may have been removed for cleaning or to prevent tripping hazards, and the assigned CNA was unaware of the resident's need for a floor mat due to lack of familiarity with his care plan. Further interviews with nursing staff and facility leadership confirmed that the floor mat was a required intervention for fall prevention and should have been in place whenever the resident was in bed. The facility's policy on fall prevention emphasized the importance of implementing individualized interventions and educating staff about safety measures. The failure to ensure the floor mat was in place as specified in the care plan resulted in noncompliance with the requirement to provide comprehensive care planning and implementation for the resident's needs.