Failure to Implement Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement a fall prevention intervention for a resident with a history of falls, impaired cognitive function, and decreased mobility. The resident's care plan required the use of a chair alarm due to impulsivity and a high risk for falls, as documented in both the care plan and fall risk evaluation. Despite these documented interventions, surveyors observed on multiple occasions that the resident did not have a chair alarm in place while seated in the wheelchair. The resident reported attempting to transfer independently and having experienced multiple recent falls, and was observed with faded bruising on both arms and the right temple. Staff interviews confirmed awareness of the care plan requirement for a chair alarm, but the intervention was not consistently implemented.