Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the environment for a resident with significant fall risk remained as free from accident hazards as possible and that adequate supervision and assistance devices were provided. The resident, an elderly man with dementia, bipolar disorder, aphasia, and deafness, was assessed as having severe cognitive impairment and required extensive assistance with bed mobility and transfers. His care plan included interventions such as keeping the bed in the lowest position and using a fall mat, based on his history of falls and risk factors including gait and balance problems, unawareness of safety needs, and hearing impairment. Despite these documented interventions, observations on multiple occasions revealed that the resident's bed was not in the low position and no fall mat was present in his room while he was in bed. Staff interviews confirmed that the resident did not have a fall mat in place and that some staff were unaware of the specific fall interventions required for him. The resident had experienced previous falls, including unwitnessed incidents where he was found on the floor next to his bed, and documentation indicated that a fall mat was to be used as an intervention following these events. The facility's own fall prevention policy required individualized care plans and environmental modifications such as keeping beds in the low position and using fall mats or similar devices for residents at risk. However, these interventions were not consistently implemented for this resident, as evidenced by the lack of a fall mat and improper bed positioning during the survey period. This failure to follow the care plan and facility policy resulted in a deficiency related to accident hazards and supervision.