Failure to Implement Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to provide care in accordance with a resident's comprehensive care plan for fall prevention. The resident, who has diagnoses including dementia, visual loss, and a history of falls, was identified as high risk for falls due to factors such as poor balance, unsteady gait, blindness, and dementia. The care plan and physician orders specified that the resident should have hip protectors in place at all times unless being laundered. However, during the survey, it was observed that the resident was not wearing hip protectors as required. Interviews with staff revealed a lack of awareness and follow-through regarding the use of hip protectors for this resident. A CNA stated she was only aware of fall mats and a low bed as interventions, and upon inspection, confirmed the absence of hip protectors. An RN acknowledged that the resident was supposed to have hip protectors but had not had them since transferring to the current unit several months prior. The LTC manager also confirmed the resident should have had hip protectors in place but was unsure why they were not being used.