Failure to Implement Fall Prevention Interventions and Obtain Required Physician Orders
Penalty
Summary
The facility failed to ensure that a resident identified as a fall risk was provided with adequate accident prevention measures as outlined in his care plan. Specifically, the resident, who had severe cognitive impairment, muscle weakness, and required extensive assistance with activities of daily living, did not have a physician order for the scoop mattress used on his bed. Additionally, the fall mat, which was an intervention listed in his care plan to prevent injury from falls, was observed leaning against the wall rather than being placed alongside the bed while the resident was in it. Interviews with nursing staff, including an RN, the DON, and the ADON, confirmed that the fall mat should have been positioned next to the resident's bed whenever he was lying in it, and that a physician order was required for the scoop mattress. The facility's policy on physical restraints also indicated that such devices should only be used with appropriate medical justification and orders. The lack of proper placement of the fall mat and absence of a physician order for the scoop mattress constituted a failure to provide an environment free from accident hazards and to implement necessary interventions for accident prevention as specified in the resident's care plan.