Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease, who was identified as being at risk for falls, did not have required fall prevention interventions in place as outlined in their care plan. The resident's care plan specified that a floor mat should be placed next to the bed and that the call light should be within reach before leaving the room. On the date of the incident, the resident was found lying face down on the floor beside the bed with a bloody nose, and it was documented that neither the floor mat was present nor the call light within reach at the time of the fall. Interviews with facility staff, including CNAs and an RN, confirmed that fall interventions are communicated through care plans and CNA care cards, and that these interventions are expected to be in place for residents at risk of falling. The Nursing Home Administrator also acknowledged that staff are expected to follow the care plan and that the interventions for this resident were not implemented at the time of the incident.