Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall and injury prevention interventions for one resident as required by its own fall management policy. The policy stated that the interdisciplinary team would review falls, discuss and care plan recommended interventions, and update the care plan and Kardex accordingly. A resident with Alzheimer's dementia, cognitive impairment, and a recent history of falls was found on two separate occasions sitting or lying on the floor after apparent falls. After the first fall, the care plan was updated to include the use of non-skid socks at bedtime as a preventive measure. Despite this intervention, the resident experienced a second fall in her room during the early morning hours. Documentation and staff interviews confirmed that the resident was not wearing non-skid socks at the time of the second fall, as required by the updated care plan. The Director of Nursing verified that the intervention was not in place when the incident occurred. This failure to ensure that the prescribed fall prevention measure was implemented resulted in a deficiency under the cited nursing services regulation.