Failure to Implement Fall Prevention Interventions as Outlined in Care Plan
Penalty
Summary
The facility failed to fully implement a comprehensive, person-centered care plan for a resident identified as being at high risk for falls. The resident, a male with a history of a displaced femur fracture, atherosclerotic heart disease, bipolar disorder, dementia, and anxiety, required extensive assistance with activities of daily living and had experienced multiple falls both prior to and during his stay. His care plan and Kardex specifically required that fall mats be placed on both sides of his bed as a fall prevention measure. However, during observations, only one fall mat was present on the right side of the bed, with none on the left side as required by his care plan. Interviews with the resident, his family member, the DON, an RN, and a CNA confirmed that the care plan intervention was not fully implemented. Staff members acknowledged the importance of having mats on both sides of the bed and indicated that they referenced the care plan and Kardex for guidance, but failed to notice or address the missing mat. The facility's own policies required comprehensive care plans with measurable objectives and the implementation of fall prevention interventions based on individual risk factors, but these were not followed in this instance.