Failure to Implement Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
Staff failed to implement and maintain required fall prevention interventions for two residents identified as being at high risk for falls. One resident with Parkinson's disease and moderate cognitive impairment had a care plan specifying the use of bed and chair alarms to alert staff of self-ambulation and a restriction against raising the footrest of the recliner. Despite these interventions, the resident was found on the floor with a reopened suture above the right eye after staff did not activate the bed alarm when assisting the resident to bed. Additionally, staff were observed raising the recliner footrest, contrary to the care plan instructions, and some staff were unaware of the need for a bed alarm. Another resident with dementia, multiple sclerosis, and a history of falls had a care plan requiring bed and chair alarms and two-person pivot transfers with a gait belt and walker. The resident experienced multiple falls when staff failed to ensure the presence of required alarms. On one occasion, the resident fell and sustained a hip fracture after the chair alarm was not in place, and the sensor pad was found on the floor. Staff interviews revealed a lack of awareness regarding the need for chair alarms, and the resident was last seen in a wheelchair before self-transferring and falling. The facility's own Falls Program policy required staff to check for correct application of care-planned interventions at the beginning of every shift, including alarms and other safety devices. Despite this policy, staff did not consistently follow care plan interventions for fall prevention, resulting in multiple falls and injuries for both residents.