Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that fall prevention interventions were in place for a resident identified as being at risk for falls. The resident, who had multiple diagnoses including COPD, dementia, neuromuscular dysfunction of the bladder, hypertension, diabetes with polyneuropathy, major depressive disorder, and carpal tunnel syndrome, was assessed as cognitively intact and had no prior falls since admission. After an unwitnessed fall in which the resident slipped on a wet towel outside the shower, the root cause was determined to be the lack of non-skid strips in front of the shower. Although the care plan was updated to include non-slip strips as an intervention, observation and staff interview confirmed that these strips were not present in the resident's bathroom at the time of review. Facility policy required staff to implement interventions based on identified risks and causes to prevent falls, but this was not followed in this instance.