Failure to Provide Required Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that a resident identified as being at risk for falls received adequate supervision and assistive devices as outlined in their care plan. Specifically, the resident, who had diagnoses including schizoaffective disorder, dementia, and anxiety disorder, was assessed as having severely impaired cognition and significant functional limitations. The resident's care plan required the bed to be maintained in the lowest position and the use of bilateral floor mats to prevent falls. Despite these interventions being documented, multiple observations showed the resident's bed was in the highest position and no floor mats were present. These observations occurred on more than one occasion, and staff confirmed that floor mats were not in use in the resident's room. The resident had a documented history of multiple falls, with incidents occurring both on and off the floor mats, and was known to be non-compliant and to get up independently. The facility's policies required individualized fall prevention interventions and regular monitoring by nursing supervisors to ensure compliance with care plans. However, interviews with staff, including a CNA and the DON, revealed that the required interventions were not consistently implemented, resulting in the resident being left without the necessary fall prevention measures as specified in their care plan.