Failure to Consistently Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to consistently implement fall prevention interventions for a resident assessed as high risk for falls. The resident had a history of repeated falls, cognitive impairment, muscle weakness, and required substantial assistance with mobility and activities of daily living. The care plan included interventions such as fifteen-minute safety checks while sleeping and grip strips on the floor near the bed, but these were not reliably carried out. Specifically, safety checks were not completed for over three hours on one occasion, during which the resident experienced an unwitnessed fall resulting in head lacerations. Additionally, grip strips were not present at the bedside during observations, and staff confirmed these were not placed after the resident changed rooms. Staff interviews revealed inconsistent implementation and documentation of the prescribed interventions. The DON and ADON acknowledged that grip strips were not installed in the new room and that 15-minute safety checks were not always performed or properly documented. The ADON also indicated that the checks were not consistently listed as care plan interventions and that CNAs did not always follow the intended protocols. Observations further showed the resident was at risk while seated in a Broda chair, with poor posture and sliding down, requiring staff assistance. The facility's own policy required staff to identify and implement interventions based on the resident's specific risks and to monitor and adjust these interventions as needed. Despite the resident's high fall risk and documented history of falls, the facility did not ensure that the care plan interventions were consistently in place or that staff adhered to the established protocols, leading to preventable lapses in supervision and safety.