Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
Facility staff failed to consistently implement the comprehensive care plan for a resident with multiple risk factors for falls, including dementia, repeated falls, muscle weakness, anxiety, and osteoporosis. The resident's care plan specifically required fall mats to be placed on each side of the bed due to their high fall risk and history of falls, including incidents resulting in minor injury. During a surveyor's observation, it was noted that there was no fall mat on the left side of the resident's bed, contrary to the care plan's directive. Both fall mats were found on the right side of the bed, which was confirmed by the unit manager as not meeting the care plan's requirements. Review of facility documentation and staff interviews revealed that the omission occurred after the certified nursing assistant had assisted the resident to the toilet and failed to return the fall mat to its proper position. The facility's Falls Management Program policy requires that identified interventions, such as fall mats, be incorporated into the care plan and implemented accordingly. Despite these policies and the resident's documented need for bilateral fall mats, the intervention was not consistently maintained, as evidenced by the surveyor's findings and staff acknowledgment.