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 significant cognitive impairment and multiple risk factors for falls. The resident had diagnoses including diabetes mellitus, senile degeneration of the brain, and dementia, with a Brief Interview for Mental Status (BIMS) score of zero, indicating severely impaired cognition. The resident was dependent on staff for bathing and toileting and had a documented history of multiple falls with injury. The care plan included specific interventions such as placing nonskid strips in front of the recliner, ensuring the call light was within reach, placing a fall mat next to the bed, keeping the bed in the lowest position, checking the resident every two hours, and providing non-slip socks. Observations and staff interviews revealed that these interventions were not consistently implemented. A CNA reported not having access to the care plan and relied on daily reports to determine which residents required fall mats or low bed positions. A licensed nurse was unsure if all staff had access to the care plan and was unclear about the requirements for bed positioning. The administrative nurse confirmed that fall mats should be placed on the side of the bed, not underneath, and that the last staff member leaving the room should ensure interventions were in place. During the survey, the fall mat was found under the resident's bed and had to be repositioned by the administrative nurse. The facility's policy required individualized interventions based on assessment, but these were not consistently followed for the resident in question.