Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement comprehensive, person-centered care plan interventions for a resident with a history of falls and multiple diagnoses, including unspecified dementia with psychotic disturbance, delirium, and adult failure to thrive. The resident's care plan identified specific fall prevention interventions, such as placing a 'Call don't fall' sign in the room and installing autolocking brakes on the wheelchair. These interventions were documented in the care plan with specific dates for implementation. However, during surveyor observation, neither the required signage nor the autolocking brakes were present for the resident. Interviews with a CNA and the Director of Nursing confirmed that these interventions were supposed to be in place, with the CNA referencing the care card and the DON noting the sign was found in the resident's drawer and that the resident may not have had their usual wheelchair. The lack of these interventions indicated that the facility did not follow its own policy or the resident's care plan to address identified fall risks.