Failure to Implement Fall Prevention Interventions per Care Plans
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for three residents. One resident with osteoporosis, Alzheimer's disease, and chronic pain had a history of unwitnessed falls, including one resulting in a hip fracture. Despite a care plan intervention requiring appropriate footwear, the resident was observed wearing regular socks without non-skid features or shoes while in the dining room. Staff confirmed the absence of non-skid socks and acknowledged the resident should have been wearing tennis shoes. Another resident with Alzheimer's disease and multiple psychiatric diagnoses had a care plan intervention for non-skid strips to be placed both beside her bed and in front of her chair. Observation revealed that while strips were present beside the bed, they were missing in front of the recliner, and the weekend supervisor was unaware of this requirement. A third resident with dementia and heart failure, who required substantial assistance with transfers and had a recent fall with injury, had a care plan intervention for a pommel cushion to prevent leaning and potential falls. Observations showed the resident was seated in a wheelchair without the pommel cushion, and staff were either unaware of what the cushion was or stated it was unavailable due to being soiled. The DON later indicated that hospice was responsible for providing the cushion, but it had not been supplied, and an alternative cushion was used without proper documentation in the care plan. These findings demonstrate that the facility did not ensure fall prevention interventions were consistently in place as specified in residents' care plans.