Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions as outlined in the care plan for a resident with severe cognitive impairment, anoxic brain damage, and muscle weakness. The resident, who was dependent on staff for activities of daily living and identified as a fall risk, was observed lying in bed with an air mattress while the bed was in a high position, contrary to the care plan intervention requiring a low bed. No staff were present in the room at the time of observation. A CNA confirmed that the bed had been left in a high position after the resident's husband, who had previously raised the bed during visits, had left the facility, and the bed was not lowered as required. Facility policy required that fall risk interventions be initiated and monitored for effectiveness, but this was not followed in this instance.