Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency was identified when a facility failed to implement fall prevention interventions for a resident who had experienced multiple falls and was assessed as high risk for falls. The resident's care plan included specific interventions such as frequent rounding, bilateral fall mats, and ensuring a call pad was within reach and placed on the side of the bed where the resident was most likely to fall. Despite these documented interventions, observations by the surveyor on two separate occasions revealed that the call pad was not within the resident's reach and was not positioned on the correct side of the bed, as required by the care plan. Instead, the call pad was found on top of a suctioning container and, at another time, on top of an oxygen humidifier machine. Interviews with the resident's representative and facility staff, including the ADON, confirmed that the call pad was not consistently placed according to the care plan. The resident's representative provided photographic evidence of the improper placement, and the ADON acknowledged that the required interventions were not in place at the time of the observations. The administrator and DON were notified of these concerns regarding the lack of adherence to fall prevention measures for the resident.