Failure to Implement Care Planned Fall Safety Interventions
Penalty
Summary
The facility failed to implement care planned interventions for fall safety for a resident with hemiplegia and hemiparesis following a stroke, who was severely cognitively impaired and required total assistance for activities of daily living. The resident's care plan identified a risk for falls related to muscle weakness and reduced mobility, specifying the use of bilateral fall mats at the bedside as an intervention. However, during multiple observations, the resident was found lying in bed without fall mats present on either side. Interviews with nursing staff, including a nursing assistant and a nurse assigned to the resident, revealed that they were not aware of the care plan requirement for bilateral floor mats for fall injury prevention. The MDS Coordinator confirmed that the resident was actively care-planned for the use of bilateral floor mats, and both the Director of Nursing and the Administrator acknowledged that staff should have followed the care plan and provided the mats as indicated.