Failure to Follow Fall Prevention Interventions as Ordered
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the resident's care plan and physician orders. Specifically, a resident with diagnoses including unspecified dementia and Type 2 Diabetes Mellitus with chronic kidney disease was observed multiple times in bed without the required fall mat in place. The care plan and physician order both specified that a fall mat should be positioned on the exit side of the bed at all times when the resident was in bed. However, on several occasions, the fall mat was observed leaning against the wall rather than on the floor as required. Interviews with nursing staff, including an RN and the DON, confirmed that the fall mat should have been in place whenever the resident was in bed, in accordance with the physician's order. The RN stated that the mat was not on the floor due to a broken bed, but could not explain why this prevented the use of the fall mat. The DON and LPN/Unit Manager both affirmed that the fall mat was necessary for resident safety and should be used as ordered. The deficiency was identified through observations, interviews, and review of the resident's medical record and care plan.