Failure to Implement and Maintain Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement and maintain appropriate interventions to prevent accidents for two residents identified as being at risk for falls. For one resident with chronic kidney disease, vascular dementia, and a history of failure to thrive, the care plan included interventions such as bilateral body pillows, keeping the bed in the lowest position, and placing fall mats on both sides of the bed. Despite these interventions being documented in the care plan following a fall from bed, repeated observations showed that the bed remained approximately two feet off the floor and fall mats were not present as required. Staff interviews revealed that the interdisciplinary team had decided against the use of fall mats, but they were still included in the care plan and thus should have been implemented. The bed provided by hospice could not be lowered further, and staff had communicated this limitation to administration multiple times. Another resident with chronic obstructive pulmonary disease and depression was also identified as being at risk for falls, with care plan interventions specifying a fall mat to the right side of the bed and keeping the bed in the lowest position. After an unwitnessed fall, it was documented that neither the fall mat was present nor was the bed in the lowest position at the time of the incident. Subsequent observations confirmed that these interventions continued to be absent, with the resident found in bed without a fall mat and the bed not in the lowest position. Interviews with facility leadership confirmed that the expected interventions, as outlined in the residents' care plans, were not consistently implemented. The failure to provide and maintain these interventions, despite being care planned and necessary for the residents' safety, constituted a deficiency in ensuring the environment was free from accident hazards and that adequate supervision and assistance were provided to prevent accidents.