Failure to Implement Physician-Ordered Fall Precaution for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident identified as high risk for falls was free from accident hazards, as required by both physician order and facility policy. Specifically, the resident, who had severe cognitive impairment, Alzheimer's disease, dementia, and poor safety awareness, was supposed to have a floor mattress placed at the bedside as a fall precaution. Despite a care plan and a physician's order for the use of a floor mattress, observations revealed that the mattress was not in place while the resident was in bed; instead, it was found leaned against the wall. Medical record review confirmed the resident's high fall risk and the need for the floor mattress intervention. Staff interviews corroborated that the mattress should have been in place at all times when the resident was in bed, especially given the resident's history of attempting to get out of bed and a previous fall incident. The failure to implement this safety intervention as ordered constituted a deficiency in providing adequate supervision and accident hazard prevention.