Failure to Implement Care Planned Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision and assistive devices as care planned for two residents. For one resident with dementia, diabetes, and a history of falls, the care plan required anti-slip strips to be placed in front of her recliner and dresser/shelving due to her poor balance, impaired mobility, and previous falls. However, observation revealed that these anti-slip strips were not present in her room. The resident had recently sustained a significant head injury from a fall, and both the DON and the resident confirmed the absence of the required anti-slip strips. The DON acknowledged that the facility was not following the care plan for this resident. Another resident, who was severely cognitively impaired, had a history of falls and required staff assistance for transfers. His care plan included the use of an anti-slip device (sheet) in his wheelchair to aid in positioning and prevent falls. Observation and interview with the DON confirmed that the anti-slip sheet was not present in the resident's wheelchair, despite being a documented intervention in his care plan. The DON stated that if an intervention was on the care plan, it should have been implemented. The facility's own policy on fall prevention required staff to implement and monitor interventions identified in the care plan to reduce the risk of falls and accident hazards. In both cases, the facility did not follow through with the care planned interventions intended to prevent accidents, as evidenced by the absence of anti-slip devices for both residents who were at high risk for falls.