Failure to Provide Required Fall Prevention Devices
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for one resident. According to the facility's policy on managing falls and fall risk, staff are required to implement interventions based on each resident's specific risks, including the use of bilateral fall mats as indicated in the care plan. Review of the clinical record for a resident with dementia and hypertension showed that fall mats were to be in place at both sides of the bed, as documented in the care plan. However, during observations on two separate occasions, the resident was found lying in bed without any fall mats present, and none were found in the room. In a subsequent interview, the Nursing Home Administrator confirmed that the fall mats were not in place as required by the care plan.