Failure to Implement Care-Planned Fall-Prevention Interventions for Two Residents
Penalty
Summary
Surveyors identified a failure to implement care-planned fall-prevention interventions for two residents assessed as being at risk for falls. For one resident with dementia, gait abnormalities, muscle weakness, and a history of falls with injury, the care plan dated 05/20/22 included interventions such as "call don't fall" signage in the room, keeping the bed in the lowest position, and placing nonskid strips in front of the bed. During observation on 01/08/26, the resident was found lying in bed with the bed not in the low position, no "call don't fall" signage present, and the bed positioned over the nonskid strips. The CNA present confirmed the resident was at risk for falls, verified the bed was not low, stated she did not remember ever seeing the signage, and confirmed the bed was over the nonskid strips. For another resident with systemic lupus erythematosus, cerebral palsy, muscle weakness, impaired balance, use of psychotropic medications, history of TIA, impulsive behaviors, and two or more prior falls, the care plan initiated 11/11/20 included an intervention to apply dycem to the wheelchair, with this intervention dated 01/26/21. A fall risk assessment showed the resident was at moderate risk for falling. On observation with an LPN on 01/08/26, the resident was sitting in a chair and then transferred to bed; the LPN confirmed there was no dycem in the chair or in the room, and the resident did not recall ever having dycem in the wheelchair. Record review with the LPN confirmed the care plan required dycem to be applied to the chair. A progress note dated 01/09/26 documented that another nurse found the resident on the floor in another resident’s room and stated dycem was in place in the chair, but in a later interview the LPN clarified that dycem was not in the chair at the time the resident was found on the floor and that dycem was applied only afterward. The facility’s fall policy required review of the care plan and documentation of appropriate interventions to prevent future falls.
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