Failure to Provide Verbal Reminders Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to implement a post-fall intervention established by the Interdisciplinary Team (IDT) for a resident with legal blindness, a history of falls, and muscle wasting. The intervention required staff to provide verbal reminders and cues to the resident to request assistance as needed. On the day of the incident, a CNA assisted the resident to the bathroom but left the resident seated on the toilet to close a sliding door, without providing a verbal reminder to remain seated or to call for help before standing. The CNA assumed the resident would stay seated, but the resident attempted to stand up independently and subsequently fell, resulting in a head injury that required hospitalization. Review of facility records confirmed that the resident had a prior unwitnessed fall and that the IDT had specifically recommended verbal reminders as a preventive measure. The Director of Nursing acknowledged that staff should consistently educate the resident on the importance of asking for help before getting up. The facility's fall protocol also emphasized monitoring and documenting the effectiveness of interventions for residents at high risk of falls. The failure to provide the required verbal reminder directly preceded the resident's fall and injury.