Failure to Prevent Accident and Assess Resident After Fall
Penalty
Summary
The facility failed to prevent an accident hazard and provide adequate supervision as required by policy and the resident's care plan. A resident with a history of falls, morbid obesity, and type 2 diabetes was being transferred from bed to wheelchair when the wheelchair brakes were not properly locked, causing the wheelchair to move and the resident to slip onto the floor. The resident required substantial assistance for transfers and had impaired balance, as documented in the care plan and assessments. The incident was not documented in the medical record, and there was no evidence of a fall being recorded for the resident on the date in question. Following the fall, certified nursing assistants (CNAs) moved the resident back to bed without a licensed nurse assessment, contrary to facility protocol. One CNA reported the fall to an LVN, who did not assess the resident or initiate a change of condition report, and instead directed the CNAs to return the resident to bed. The interim director of nursing and administrator were unaware of the incident until days later, and no investigation or required notifications were initiated at the time of the fall. The facility's policy required evaluation and documentation of all falls, which was not followed in this case.