Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions for a resident identified as high risk for falls. Medical record review showed the resident had multiple diagnoses, including palliative care, Parkinson's disease, COPD, and dementia, and was assessed with severe cognitive impairment. The care plan included specific fall prevention measures such as keeping the call bell within reach, maintaining the bed in the lowest position, ensuring the fall mat was on the left side of the bed, and not leaving the resident unattended in certain areas. Despite these interventions being documented, observations revealed that the call light was not within the resident's reach and was found wrapped under the bed wheel. Additionally, the resident's bed was observed in a high position with no staff present, and the fall mat was placed on the right side of the bed instead of the left as specified in the care plan. Staff interviews confirmed these observations, with CNAs verifying the call light was not accessible and the bed was not in the correct position. The resident had a documented history of multiple falls within the review period. The facility's policy required all accidents and incidents to be investigated and reported, but the lack of adherence to the care plan interventions contributed to the deficiency. This failure affected one resident out of three reviewed for falls in a facility with a census of 100.