Failure to Implement Care-Planned Fall-Prevention Interventions for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement fall-prevention interventions as outlined in residents’ care plans for residents identified as high fall risks. For one resident with multiple diagnoses including osteoporosis, gait abnormalities, cognitive impairment, and a history of multiple falls, the fall risk assessment identified her as high risk and her care plan required that her walker be kept within reach when she was in her room. During observation, the resident was lying in bed with her wheelchair at the bedside, but no walker was within reach as required by her fall-prevention care plan. A CNA who had been working at the facility for about four months reported being familiar with this resident, acknowledged that the resident was a fall risk with a history of falls, and stated that the resident was supposed to wear non-skid socks or shoes when ambulating and primarily used a wheelchair. However, the CNA was not aware that the resident had a walker and confirmed, upon returning to the room, that no walker was kept within the resident’s reach despite this being an active intervention in the resident’s fall-risk care plan. For a second resident with multiple conditions including hemiplegia, muscle weakness, reduced mobility, and total incontinence, the fall risk assessment also identified her as high risk for falls, and her care plan required that she be provided with a reacher/grabber and encouraged to use it, particularly if she dropped items on the floor. Observation found this resident in bed with an air mattress, perimeter overlay, assist bars, and call light within reach, but without a reacher/grabber in reach as specified in her care plan. The resident stated she had a reacher/grabber “around there somewhere” but confirmed it was not within reach, and a reacher/grabber was later observed stored on a nightstand in an area of the room not accessible to her. An LPN, new to the facility, confirmed that the reacher/grabber was part of the resident’s fall-prevention interventions and that it was not within the resident’s reach at the time of observation. The facility’s fall policies required identification and implementation of interventions based on resident-specific risks, but the required interventions were not in place for these residents at the time of surveyor observations.
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