Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement the care plan interventions related to fall prevention for one resident. According to the facility's policies, comprehensive care plans must be developed and implemented to address each resident's specific needs, including fall risk interventions. The resident in question had a history of cerebral infarction, Alzheimer's disease, dementia with behaviors, diabetes, osteoarthritis, chronic pain, dysphagia, and muscle weakness, and was identified as being at risk for falls due to weakness and unstable mobility. The care plan included interventions such as keeping the bed in the lowest position and placing bilateral fall mats at the bedside, especially after multiple attempts by the resident to get out of bed without assistance. Despite these documented interventions, multiple observations over several days revealed that the resident's bed was not in the lowest position and fall mats were not present at the bedside. Staff interviews confirmed a lack of awareness and implementation of the prescribed fall interventions. The Wound Care Nurse was unaware of the resident's fall interventions and could not recall the last time fall mats were present, while the DON confirmed the absence of fall mats and the failure to implement the care plan as required.