Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that three residents received adequate supervision and assistance devices to prevent accidents, as required by their individualized care plans and the facility's fall prevention policy. For one resident with hemiplegia and a history of falls, staff transferred the resident to the toilet and left them alone in the bathroom, resulting in an unwitnessed fall. Multiple staff interviews confirmed that the resident should not have been left unattended due to their need for assistance with transfers, and the care plan was not updated with new interventions following the incident. Documentation and interviews revealed that staff were aware of the resident's tendency to self-transfer, yet no additional measures were implemented to address this ongoing risk. For a second resident with severe cognitive impairment and high fall risk, surveyor observations repeatedly found that required fall interventions, such as a fall mat beside the bed and the call light within reach, were not consistently in place. On several occasions, the fall mat was folded against the wall or missing, and the call light was either out of reach or behind the resident's pillow. Nursing staff did not ensure these interventions were implemented, even after providing care in the resident's room. The resident's care plan and care card specified these interventions, but they were not reliably followed during the survey period. A third resident, also with severe cognitive impairment and high fall risk, was observed multiple times without key fall prevention interventions in place. These included the absence of a fall mat, body pillows, Dycem in the wheelchair, and the call light within reach, despite these being listed in the resident's care plan and care card. The resident's bed was not consistently kept in the low position as required, and personal items were not always within reach. Staff interviews indicated reliance on care cards for intervention information, but surveyor observations demonstrated that interventions were not consistently implemented for this resident.