Failure to Ensure Assistance Devices for Resident Safety
Penalty
Summary
The facility failed to ensure that assistance devices to prevent accidents or injury were in place for three residents. Resident 13, who was cognitively impaired and required assistance for daily care, had a physician's order for a chair alarm on his wheelchair. However, during an incident on July 20, 2024, the chair alarm was not present, and the resident fell while attempting to move from his wheelchair to the bathroom. The Director of Nursing confirmed the absence of the chair alarm at the time of the fall. Resident 17, who was cognitively intact but at high risk for falls due to deconditioning and gait balance problems, experienced two falls where the chair alarm was not functioning. On October 5, 2024, the resident slid off his wheelchair while trying to plug in a radio, and on November 11, 2024, he was found on the floor with an abrasion on his back. In both instances, the chair alarm did not sound. Resident 24, who required assistance and had Alzheimer's disease, was not transferred using a sit-to-stand lift as ordered, leading to a fall on June 11, 2024. The Director of Nursing confirmed that the sit-to-stand lift was not used during the transfer.
Plan Of Correction
Resident 13 and 17 chair alarm is in place and functioning. Resident 24 transfer status reviewed and remains unchanged. Baseline audit was completed on residents that have assistive devices in place. Director of Nursing provided education to nursing staff related to checking placement of assistive devices (e.g. fall mats, alarms, transfer device). Monitoring will be captured through auditing assistive devices. Audits for assistive devices in place will be conducted as follows: 4 clinical records will be reviewed weekly for 4 weeks, then 10 clinical records will be reviewed 2 times monthly for 2 months. The audits will be conducted by the Director of Nursing or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.