Failure to Implement Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement required fall prevention interventions for two residents identified as being at risk for falls. One resident, admitted with chronic obstructive pulmonary disease, hemiplegia, hemiparesis, and cerebral infarction, had a care plan indicating a moderate fall risk due to confusion, deconditioning, and unawareness of safety needs. The care plan specified that fall mats should be placed on both sides of the bed following two documented falls. However, during two separate observations, the resident was found in bed without the required bilateral floor mats in place. A nurse aide confirmed the absence of the mats during these times. Another resident, admitted with amyotrophic lateral sclerosis and myasthenia gravis, also had a care plan intervention for bilateral fall mats due to fall risk. Observation revealed that only one fall mat was present on the right side of the bed, rather than on both sides as required. This was confirmed by an LPN. These failures to follow the specified safety interventions in the residents' care plans resulted in the deficiency.
Plan Of Correction
1. Identified residents were immediately provided with fall mats as care planned. 2. Residents with care plan for fall mats were audited to ensure the fall mats were properly in place. 3. Random audits will be conducted weekly x 4 and monthly x 3 for residents with an order for floor mats to ensure placement as indicated. 4. Results of the audits will be reported to QAPI committee for results, areas of improvement and/or continuation of audits.