Failure to Implement Fall Prevention Interventions as Directed by Care Plan
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for a resident with multiple medical conditions, including hypertension, diabetes, a history of stroke, pelvic fracture, dysphagia, aphasia, and severe cognitive impairment. The resident was dependent on staff for all activities of daily living except eating, was nonverbal or rarely understood, and used a staff-propelled Broda chair for mobility. The care plan specified that the resident's bed should be kept in the lowest position, a fall mat should be placed next to the bed, and the call light should be within reach. However, during observations, the call light was found out of the resident's reach, and the fall mat was not positioned next to the bed as required, but instead was folded up next to the Broda chair. Interviews with facility staff, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, confirmed that call lights should be within reach and fall mats should be placed by the bed for residents who require them. The facility's own policy emphasized the importance of maintaining an environment free from accident hazards and prioritizing resident safety and supervision. Despite these policies and care plan directives, the required fall prevention measures were not consistently implemented for this resident.