Failure to Implement Care-Planned Fall Intervention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall intervention for a resident identified as being at risk for falls. The resident was admitted with diagnoses including high blood pressure, hallucinations, weakness, and cognitive communication deficit. A Falls Risk Observation completed at admission showed a moderate fall risk with a score of eight, and a subsequent Falls Risk Observation increased the resident’s status to high risk with a score of 14. A Safety Event report documented that the resident experienced a fall without injury when found lying on the floor beside the bed in the early morning hours, with the only intervention in place at the time being the bed in the lowest position. Following this fall, the resident’s fall care plan was revised to include a perimeter mattress to help define the edges of the bed. However, during a later observation, surveyors noted that the resident’s bed had a regular flat mattress with no perimeter sides in place. In an interview, the ADON confirmed that the resident did not have a perimeter mattress and instead had a regular flat mattress, and stated that the resident had moved into the current room sometime in October. Review of the facility’s Fall Investigation policy showed that the interdisciplinary team is required to review current interventions and implement additional fall interventions based on residents’ risk factors, but the perimeter mattress intervention that had been added to the care plan was not in place for this resident.
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