Failure to Follow Fall Prevention Interventions
Penalty
Summary
The facility failed to follow fall prevention interventions as outlined in the individual comprehensive care plan (ICCP) for a resident identified as being at high risk for falls. The resident, who was admitted with diagnoses including Parkinson's disease and dementia, was observed in a reclining chair without the thick cushioned fall mat that was supposed to be placed next to their bed as per the care plan. The resident's ICCP included specific interventions such as keeping the bed in the lowest position and placing a thick floor mat and landing strips next to the bed. However, during an incident, these interventions were not in place, leading to the resident sustaining a hematoma and laceration after a fall. The investigation revealed that the bed was not in the lowest position at the time of the fall, and the floor mats were not in place, contrary to the care plan. The CNA responsible for the resident at the time was an agency staff member unfamiliar with the resident's specific needs. The Director of Nursing acknowledged that the care plan was not followed, and the Registered Nurse/Unit Manager emphasized the importance of adhering to the care plan to ensure the best outcomes for residents. The facility's policy required that interventions be implemented for residents with a high fall risk score, but this was not adhered to in this case.
Plan Of Correction
The root cause for this deficient practice was the nurse failed to properly oversee the agency aide assigned to resident #44 to ensure the appropriate interventions were in place when the resident was in bed. The nurse was re-educated on her responsibility to oversee the care provided by a CNA and to ensure the residents under her care have the appropriate safety interventions in place. All residents who are severely cognitively impaired, have a fall risk score above 10, and who have fall interventions of a low bed and floor mats, have the potential to be affected by this deficient practice. Residents Fall Risk Scores, BIMS scores, and Care Plans will be reviewed to identify residents at risk to ensure the information provided on the Resident Care Needs form is accurate. The unit managers/nursing supervisors will be educated on checking the daily staffing sheet to identify any agency staff assigned in the facility and will ensure they have received the Resident Care Needs form, which was created to easily and quickly be able to identify the care needs of residents. Licensed nursing staff will be re-educated on their responsibility to provide supervision and oversight to any CNA providing care to a resident under their care and to ensure all safety interventions are in place. A weekly Agency Staff Supervision form will be in the staffing office with the daily staffing sheets. The unit managers/nursing supervisors will complete this form daily. The form will be reviewed by the DON weekly x 12 weeks, then monthly x3 months to ensure agency staff have received the necessary information to provide safe resident care. The results of the reviews will be presented at the quarterly quality assurance meetings for the March and June meetings.