Failure to Prevent Accidents and Hazards for Residents
Penalty
Summary
The facility failed to prevent accidents and hazards for two residents, leading to deficiencies in their care. Resident 35, diagnosed with Alzheimer's disease and severe cognitive impairment, experienced an unwitnessed fall in the bathroom. The resident's care plan required assistance with toileting and transfers, yet the resident was left alone in the bathroom without the ability to use the call bell due to cognitive limitations. Interviews with staff revealed that the resident did not understand how to use the call bell and would often yell for assistance instead. The Nursing Home Administrator acknowledged that the resident should not have been left alone, and the staff member involved was terminated. Resident 47, diagnosed with dementia and hypertension, was identified as a fall risk with a care plan intervention to have a fall mat placed on the left side of the bed when in bed. However, an observation revealed that the fall mat was not in place when the resident was out of bed, contrary to the care plan instructions. A previous incident note indicated an unwitnessed fall where the fall mat was not in place, and staff had been educated on ensuring the mat was properly positioned. These lapses in following care plans and providing adequate supervision contributed to the deficiencies noted in the report.
Plan Of Correction
1. R35 resides at the facility and R47 no longer resides at the facility, both residents have the potential to be impacted by the deficient practice. The IDT team met and reviewed R35 fall care plan to ensure it reflects appropriate interventions that is appropriate for residents' clinical diagnosis that includes dementia (a brain disorder that causes a decline in cognitive function, memory, and behavior, severe enough to interfere with daily life). 2. Current residents will have their fall risk assessment reviewed and residents identified at risk will have a care plan update to ensure appropriate interventions are in place. This includes conducting a fall mat audit by the DON and Facilities Director to ensure care plans match fall mat policy and resident care needs and positioning of the mat, if deemed necessary to prevent future occurrence by March 14, 2025. 3. A fall packet will be placed on the nursing units that will include a list of possible interventions to initiate post fall. The DON and IDT Team will be re-educating staff on February 26, 2025, on the implementation of interventions immediately post fall and observance of residents who may not be in compliance with call bell protocol or lack awareness of usage to review and guide the team to the appropriate interventions. All falls will be reviewed in the clinical daily meeting with the IDT team to ensure an appropriate intervention has been added to the resident's care plan. 4. Falls that occurred will be reviewed by the DON and clinical team weekly for 4 weeks, then monthly for 3 months to ensure appropriate interventions are initiated, added to the care plan and in place, along with auditing of the use of mats for the individual resident. This plan of correction will be monitored at the monthly Quality Assurance meeting until consistent substantial compliance has been met.