Failure to Prevent Fall Due to Malfunctioning Wheelchair and Incomplete Investigation
Penalty
Summary
A deficiency was identified when a resident with a history of unsteadiness, vascular dementia, and impaired memory experienced an unwitnessed fall in her room. The incident report noted that the resident was confused, incontinent, and had impaired memory, all of which are predisposing factors for falls. The root cause analysis indicated that the anti-rollback mechanism on the resident's wheelchair was not functioning properly at the time of the fall. Maintenance reportedly fixed the anti-rollbacks after the incident, but there was no documentation provided to confirm this repair or any inspection of other wheelchairs in the facility. Staff interviews revealed that certified nurse aides who cared for the resident before and after the fall were unaware of the incident and did not have knowledge of the anti-rollback malfunction. They stated that a malfunctioning chair would be obvious and that they would not use it if it was not working correctly. The staff also expressed concern that the resident was left unattended in her room, as she had a known history of attempting to self-transfer. The care plan for the resident included multiple fall prevention interventions, but there was no documentation of care or supervision provided immediately prior to the fall. The facility failed to provide a complete investigation of the fall, including staff statements, details of the resident's care and supervision before the incident, and records of wheelchair repairs or inspections. Despite requests from the surveyor, the Director of Nursing did not supply the full investigation or documentation related to the wheelchair's repair or the assessment of other wheelchairs. The lack of thorough investigation and documentation contributed to the deficiency cited under the requirement to ensure the resident environment is as free of accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents.
Plan Of Correction
1. Resident #17 still currently resides in the facility. Her plan of care has been reviewed and she has not had any additional falls. 2. Like residents are identified as those who have experienced a fall within the last two weeks. The plans of care for all like residents were reviewed by 4/30/2025 and updated to reflect the residents' current needs and treatment. 3. The Policy regarding fall management has been reviewed and deemed appropriate. The NHA and DON were educated on fall investigations, documentation, and follow-up by the Nurse Consultant. Licensed nursing staff were educated by the DON/designee by 4/25/2025 on fall management. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of all residents that experienced a fall in the facility to ensure their intervention was appropriate and the plan of care addresses their needs. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.