Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement the care plan for a resident with a history of falls, specifically neglecting to ensure the placement of bolster pillows on the mattress while the resident was in bed. The resident, who had diagnoses including Parkinson's Disease with significant tremors and contractures, was dependent on staff for all activities of daily living and functional mobility. Despite being identified as at risk for falls and having experienced unwitnessed falls resulting in pain and hospital transfer, the care plan interventions such as attaching bolster pillows to the mattress and positioning the resident in the center of the bed were not carried out. Observations and interviews revealed that, following the resident's falls, the care plan was revised to include specific interventions like keeping a floor mat on the left side of the bed, moving the right side of the bed against the wall, and ensuring the bed was in the lowest position. However, during multiple observations, the resident was found in bed without the required bolster pillows, and staff confirmed that the bolsters were not present. Staff interviews indicated awareness of the resident's frequent involuntary movements and the need for bolsters to prevent sliding or falling, yet the intervention was not implemented. Further review and interviews with facility staff, including the Assistant Director of Nursing, revealed that the care plan was not updated promptly after the initial fall and that the recommended interventions were not consistently applied, particularly after the resident was transferred to a different room. The lack of communication and follow-through resulted in the omission of the bolster pillows, despite clear documentation and interdisciplinary team recommendations to use them as a preventive measure for recurrent falls.