Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
Staff failed to implement fall prevention interventions as outlined in the care plan for a resident with a history of brain injury, stroke, and previous falls. The resident was assessed as high risk for falls and required substantial assistance for activities of daily living, with severe cognitive impairment. The care plan included interventions such as anticipating needs, keeping the call light within reach, using a mechanical lift for transfers, and ensuring the resident remained in supervised areas while in a wheelchair. Despite these documented interventions, a newly hired nursing assistant left the resident unsupervised in their wheelchair, resulting in the resident being found on the floor in their room. The facility's investigation identified the root cause as the failure of the new staff member to review the resident's Kardex for updated care directives, despite having completed orientation and training on reviewing care plans and Kardexes. This lapse led to the resident not receiving the required supervision as specified in their care plan.