Failure to Implement Planned Fall Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement fall care plan interventions for residents identified as being at risk for falls. One resident, an older female with intact cognition, had a documented fall and a care plan that required her bed to be kept in the lowest position and her call light to be within reach. During observation, her bed was found elevated to the highest position and her call light was on the floor, out of her reach. A Licensed Practical Nurse then lowered the bed and placed the call light within reach and acknowledged that the bed should be in the lowest position and the call light accessible to the resident. Another resident, an older male with mild cognitive impairment and assessed as high risk for falls, had two documented falls and a care plan intervention specifying the use of floor mats at the bedside. On two separate observations, no floor mat was in use or available in his room. A CNA stated they did not think this resident ever had floor mats as a fall intervention and did not see any in the room. The Unit Manager stated that the floor mat should be available as planned in the resident’s care. The facility’s fall prevention and management policy requires that residents at risk for falls have fall risk identified on the care plan with interventions implemented to minimize fall risk, which was not followed in these cases.
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