Failure to Implement Fall and Skin Tear Prevention Measures
Penalty
Summary
The facility failed to implement and maintain fall and skin tear prevention measures for a resident with significant risk factors, including severe cognitive impairment, Parkinson's Disease, congestive heart failure, and a history of falls and skin tears. Despite care plans and physician orders specifying the use of a chair alarm at all times and protective sleeves on both arms, observations revealed that the resident had two alarms attached to her chair but neither was clipped to her, and only one protective sleeve was in use while the other was left in the chair. Staff interviews confirmed a lack of understanding regarding the proper use of the alarms and the necessity of protective sleeves for the resident's fragile skin. Record review indicated multiple prior incidents of skin tears and falls, with care plans and orders updated to address these risks. However, during the survey, the required interventions were not consistently in place, as evidenced by the resident's exposed right arm and improperly applied alarms. The facility's policy mandates that interventions to reduce environmental hazards and provide adequate supervision must be implemented, but these measures were not effectively carried out for this resident.