Failure to Implement Fall Prevention Interventions
Penalty
Summary
Facility staff failed to implement assessed interventions to prevent falls for a resident with multiple risk factors, including Parkinson's disease, spinal stenosis, lumbar radiculopathy, hypertension, muscle weakness, and depression. The resident was assessed as having moderately impaired cognition and required partial to moderate assistance with several activities of daily living. The care plan identified the resident as being at risk for falls and included interventions such as the use of a pressure detection (pd) alarm in the wheelchair or bed due to the resident's non-compliance with calling for assistance. On the date of the incident, the resident was found on the floor, and documentation revealed that the call light was within reach, but the required wheelchair or bed/chair alarm was not in use at the time. Interviews with both an RN and the DON confirmed that the alarm should have been in place according to the care plan, but it was not implemented when the fall occurred.