Failure to Prevent Resident Fall Due to Inadequate Assistance
Penalty
Summary
Glen Brook Rehabilitation and Healthcare Center was found to be non-compliant with federal and state regulations regarding the prevention of abuse and neglect. The deficiency involved a failure to provide necessary care and services to prevent a fall for a resident identified as Resident B1. This resident, who was admitted with conditions including hemiplegia and hemiparesis following a stroke, required substantial assistance for transfers. Despite a care plan and physician's order specifying the need for two-person assistance during transfers, a nurse aide attempted to transfer the resident alone, resulting in the resident being lowered to the floor. The incident was documented in a nurse's note and confirmed by the facility's Nursing Home Administrator. The facility's policy on abuse, neglect, and exploitation, which was last reviewed in April 2024, mandates the provision of protections for residents' health and rights. However, the incident on December 9, 2024, revealed a breach of this policy. The nurse aide involved admitted awareness of the two-person transfer requirement but proceeded alone, leading to the resident's fall. Although the resident did not sustain visible injuries, the action posed an unnecessary risk. The Nursing Home Administrator acknowledged the failure to adhere to the care plan, which could have resulted in potential harm to the resident.
Plan Of Correction
1. Resident B1 had no adverse effect related to the incident. 2. A review of fall incidents in the last 7 days will be completed to assure that plan of care was followed to prevent a fall and provide services in order to prevent abuse/neglect. 3. The RN Staff Educator will educate nursing staff on following plan of care to prevent resident falls and policy on abuse and neglect. 4. The Unit Manager/Designee shall complete a random observational audit to verify resident transfers are being completed based on plan of care in order to prevent abuse/neglect. The audits shall be completed weekly x4 then monthly x2 or until sustained compliance is achieved. Results of audits will be reviewed by the QAPI committee. 5. POC Due Date: 01/20/2025