Failure to Follow Fall Prevention Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan designed to prevent falls. The resident, who had a history of stroke and language deficits, was assessed as being at risk for falls and required the call light to be within reach at all times. Despite this, the resident experienced an unwitnessed fall from the commode, which was later attributed to the call light not being accessible. Staff interviews and documentation confirmed that the call light was attached to the resident's bed and not near the resident at the time of the incident. Further review revealed that the investigation into the fall was incomplete, lacking information about the cause or a conclusion. The resident reported being left on the commode for 30 minutes and specifically requested not to be left unattended. Multiple staff members, including an LPN and a CNA, acknowledged that the care plan was not followed, and facility leadership confirmed that the expected protocols were not adhered to in this case.