Failure to Ensure Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards and did not provide adequate supervision and assistance devices as required by the resident's care plan. Specifically, on 06/24/2025, a resident with severe cognitive impairment, left-sided weakness, and a history of multiple recent falls was observed without a floor mat on both sides of the bed, as indicated in the comprehensive care plan. The care plan, initiated on 03/27/2025, required fall mats at the bedside due to the resident's high risk for falls. Despite this, only one mat was present during the survey observation, and there was no current physician order for fall mats or a recent fall risk assessment documented prior to the survey. Interviews with staff revealed a lack of awareness and inconsistent understanding of responsibilities regarding fall mat placement. A CNA who had recently started employment was unaware that a mat was missing, and another CNA stated that all staff were responsible for ensuring mats were in place, but ultimately the charge nurse was accountable. The ADON confirmed that nurses were responsible for correct mat placement and that all staff should check for mats when entering the room. Training on fall prevention varied among staff, with some having received it only at hiring or within the past month. The facility's Fall Prevention Program Policy required staff and physicians to identify and implement interventions to prevent falls, but these were not consistently followed for this resident.