Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall care plan interventions for three residents who were identified as being at risk for falls. For one resident with metabolic encephalopathy and multiple comorbidities, staff did not properly secure the resident in their wheelchair after toileting, resulting in the resident sliding out of the chair and falling to the floor. The care plan for this resident included interventions such as monitoring for poor positioning and using a nonskid pad, but these were not properly followed at the time of the incident. Another resident with impaired cognition due to alcohol withdrawal delirium was observed walking barefoot and later with non-grip socks, despite a care plan intervention to encourage the use of nonskid socks. This resident had a recent history of falls, including an incident where they tripped over a phone cord while attempting to get out of bed. The care plan specified the need for cues, prompting, and appropriate footwear to reduce fall risk, but these interventions were not consistently implemented. A third resident with dementia and epilepsy was observed sitting in a wheelchair with the wheels unlocked and leaning forward, despite care plan interventions requiring wheelchair brakes to be locked. The unit manager confirmed that both this resident and the previously mentioned resident were at risk for falls and that proper safety measures, such as locking wheelchairs and using gripper socks, should have been in place. The facility's own fall safety policy emphasizes the need for consistent implementation of individualized interventions to prevent falls, which was not adhered to in these cases.