Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement care plan interventions and follow facility policy to prevent falls for a resident with dementia, confusion, incontinence, reduced mobility, and end-stage Alzheimer's disease. The resident was identified as a fall risk, and the care plan included interventions such as keeping the bed in a low position, placing a fall mattress next to the bed, and conducting regular visual checks. Despite these interventions being documented, staff did not consistently ensure the fall mattress was properly positioned next to the bed as required. On one occasion, a CNA observed the resident attempting to get out of bed and sliding to the floor, after which additional fall prevention measures were added, including placing one side of the bed against the wall and using a full-thickness mattress on the open side. However, during a later observation, the fall mattress was found standing on its side rather than lying flat on the floor next to the bed. Staff interviews revealed that the CNA forgot to lay the mattress down after removing the resident's roommate, and the LPN assumed the CNA would do it, resulting in the intervention not being in place as intended. The facility's policy required that interventions to prevent falls be implemented and care plans updated as needed. Despite the resident's high risk for falls and the documented need for a fall mattress, staff failed to consistently follow the care plan and policy, leaving the resident without the required fall protection at the bedside. This lapse in following established interventions and policy contributed to the deficiency cited by surveyors.