Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement required fall prevention interventions for a resident identified as high risk for falls. The resident had multiple diagnoses, including neurocognitive disorder with Lewy bodies, Parkinson's disease, dementia, a history of falling, osteoarthritis of the right shoulder, and difficulty walking. The resident's assessments indicated severe cognitive impairment and a high risk for falls, with care plan interventions specifically outlined to address these risks. Despite the care plan listing several interventions such as the use of a fall mat, dycem in the wheelchair, a visible sign reminding the resident to call for assistance, and 15-minute safety checks, these were not consistently implemented. Observations revealed the absence of a fall mat at the bedside, no dycem in the wheelchair, and no sign displayed in the resident's room. Additionally, review of the 15-minute check documentation showed missing or incomplete records on several dates, indicating lapses in the required monitoring. Interviews with staff confirmed that the interventions listed in the care plan were not in place at the time of observation. The facility's policy required individualized interventions based on risk assessments and ongoing monitoring for effectiveness, but these were not fully carried out for the resident in question. The administrator confirmed that care plan interventions are expected to be implemented, yet several were not, resulting in a deficiency related to accident hazard prevention and supervision.