Failure to Implement Care-Planned Non-Skid Floor Strips for Fall Prevention
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall prevention intervention for a resident identified as being at risk for falls. The resident had multiple diagnoses, including multiple rib fractures, unspecified bipolar disorder, recurrent major depressive disorder, unspecified anxiety disorder, chronic pain syndrome, repeated falls, and stage IV chronic kidney disease. An annual MDS assessment documented that the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. The resident’s care plan, dated 08/14/24, identified fall risk related to refusing environmental modifications, self-medicating, alcohol use, use of mobility devices, and clutter in the room. Among the listed interventions were a cushion in the wheelchair, anti-roll backs to the wheelchair, encouraging use of the call light, a new bed/mattress, education on appropriate footwear, encouraging the resident to keep the bed in the lowest position, non-skid strips to the floor next to the bed, and family decluttering the room. Surveyor observation on 01/27/26 at 12:07 P.M. showed that the resident did not have non-skid strips on the floor beside the bed, despite this being a care-planned intervention. A CNA confirmed at the same time that there were no non-skid strips at the bedside. Later that day, a maintenance staff member verified that the resident did not have non-skid strips on the floor in the room and stated that non-skid strips would have to be ordered because none were available in the facility. On 01/28/26, the DON also confirmed that the resident did not have non-skid strips at the bedside as specified in the care plan. Review of the facility’s Comprehensive Person-Centered Care Plans policy, dated March 2022, indicated that each resident was to have a comprehensive care plan developed and implemented to meet physical, psychological, and functional needs. This deficiency was cited under a complaint investigation and was a recite to a prior annual survey.
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