Failure to Implement Fall Prevention Interventions for At-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement fall prevention interventions for a resident with multiple risk factors for falls. The resident had diagnoses including depression, anxiety disorder, cognitive communication disorder, muscle weakness, and dysphagia, and was assessed as having mild cognitive impairment with a BIMS score of 12. She required substantial to maximal assistance with activities of daily living and had a history of a non-injury fall since admission. Her care plan specified the need for a "Call, Don't Fall" sign in her room as part of her fall prevention interventions, along with instructions for staff to anticipate her needs and encourage use of the call light before transferring. Despite these documented interventions, observations on two consecutive days revealed that the required fall prevention sign was not present in the resident's room or bathroom. The resident was unable to locate the sign, and staff interviews confirmed that such signs were typically placed by the bed or toilet to prevent self-transferring. The facility's policy required staff to assess and implement interventions to ensure resident safety, and administrative staff confirmed that nurses were responsible for ensuring interventions were in place. The failure to implement the specified fall prevention intervention constituted a deficiency in providing a safe environment and adequate supervision to prevent accidents.