Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for two residents identified as being at risk for falls. For one resident, repeated observations over two days revealed that a fall mat, which was an intervention specified in the care plan following a previous unwitnessed fall resulting in fractures, was not present at the bedside. Staff interviews indicated that the resident was on hospice and unable to move independently, but the care plan still included the use of a fall mat as a preventive measure. The care plan also listed other interventions such as keeping the call light within reach, using positioning bars, and frequent checks, but the absence of the fall mat was consistently noted during multiple observations. For another resident, who was assessed as a high fall risk with severely impaired cognition, the fall mat was observed to be under the bed rather than positioned at the bedside as intended. This resident had a recent history of a fall resulting in a head laceration and abrasions, despite the fall mat being in place at the time. Staff interviews revealed some uncertainty about the exact placement of the fall mat and the circumstances of the fall, with one CNA stating they did not know why the fall mat was not present at the bedside during one observation. The care plan for this resident included multiple interventions such as a concave mattress, fall mat at bedside, and keeping the bed in the lowest position, but the implementation of these interventions was inconsistent. The deficiencies were identified through direct observation, record review, and staff interviews, which demonstrated that the facility did not consistently ensure that fall prevention interventions were in place as specified in the residents' care plans. Both residents had documented histories of falls and were assessed as high risk, yet the required safety measures were not reliably implemented, leading to a failure to provide adequate supervision and prevent accident hazards.