Failure to Implement Fall Prevention Interventions in Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan for a resident with severe cognitive impairment and high fall risk. The resident, who had diagnoses including dementia and was dependent on staff for bed mobility and transfers, had a care plan and physician orders specifying the use of a low bed and fall precautions due to a history of falls and a subdural hematoma. Despite these documented interventions, the resident was observed lying in bed with the bed not in the lowest position, contrary to the care plan and posted signage in the room. Interviews with nursing staff and the Director of Nursing confirmed that all staff were responsible for ensuring the bed was kept in the lowest position for residents at risk for falls, and that training had been provided on this intervention. The staff acknowledged the bed was not in the correct position at the time of observation, and the resident was unable to adjust the bed independently. Facility policy required comprehensive care plans with measurable objectives and timeframes, but the failure to implement the specified fall prevention intervention was directly observed.