Failure to Implement Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
Surveyors observed that the facility failed to implement fall prevention interventions for two residents identified as being at risk for falls. Both residents were found in their beds, which were not in the lowest position, despite care plans and staff interviews indicating that the beds should be kept low to reduce the risk of injury from falls. One resident was observed with a fall mat next to the bed, and both residents required assistance to get out of bed. Staff, including an LPN and a CNA, confirmed that the beds should have been in the lowest position as a fall precaution, but this intervention was not in place at the time of observation. Both residents had medical histories that included dementia and previous falls, and their care plans specifically identified them as fall risks, requiring interventions such as keeping the bed in the lowest position. Facility policy also required individualized fall prevention measures based on resident assessments. Despite these documented needs and policies, the required interventions were not consistently implemented, as evidenced by direct observation and staff interviews.