Failure to Implement Care-Planned Fall Interventions for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall interventions for two residents identified as being at risk for falls. Facility policy required licensed nursing staff, with the interdisciplinary team, to develop and implement individualized care plans to provide necessary services for each resident’s highest practicable well-being. Resident #6, admitted with a history of cerebral infarction and resulting hemiplegia/hemiparesis, had a Minimum Data Set (MDS) showing a BIMS score of 0, indicating severe cognitive impairment. The resident’s care plan, initiated after a recent hospitalization and fall, included interventions to place fall mats on both sides of the bed and to keep the bed in the lowest position while the resident was in bed. On multiple observations in February, surveyors and staff noted that fall mats were not present and the bed was not in the lowest position, despite these interventions being listed on the care plan. Resident #4, admitted with hemiplegia and hemiparesis following cerebral infarction, muscle weakness, cerebral infarction, and lack of coordination, had an admission MDS with a BIMS score of 12, indicating moderate cognitive impairment. This resident’s care plan, also initiated after a recent hospitalization and fall, identified risk for falls related to weakness and hemiplegia and directed staff to place fall mats at the sides of the bed. On repeated observations, the resident was in bed without fall mats present. Staff, including a Geriatric Nursing Assistant and the Assistant Director of Nursing, acknowledged during interviews that fall mats should have been in place according to the care plan but were not. The Director of Nursing and the Administrator both stated they expected fall interventions to be implemented, confirming that the planned interventions were not carried out as required.
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