Failure to Implement and Update Fall Interventions for Two Residents
Penalty
Summary
The facility failed to ensure that appropriate fall interventions were in place for two residents, resulting in deficiencies related to accident prevention and supervision. For one resident with multiple diagnoses including impaired mobility, cognitive impairment, and use of anticoagulant medication, the care plan was not updated with an immediate intervention following a fall. Although the interdisciplinary team later reviewed the incident and identified that the resident attempted to self-transfer while wearing Prevalon boots, which contributed to the fall, there was no evidence that an immediate intervention was added to the care plan as required by facility policy. For another resident with severe cognitive impairment and a history of falls, the care plan included an intervention to have a urinal at the bedside after a previous fall. However, during the survey, the resident was observed in bed without a urinal at the bedside, and staff confirmed that the intervention was not consistently followed. The Director of Nursing acknowledged that fall interventions should be in place but was unsure if the resident was capable of using a urinal, indicating a lack of consistent implementation of the care plan intervention.