Failure to Implement Effective Fall Interventions for High-Risk Dependent Resident
Penalty
Summary
A dependent resident with functional quadriplegia, atrial fibrillation, bradycardia, and hypertensive heart disease was assessed as high risk for falls and required staff assistance for all activities of daily living. The resident's care plan included interventions such as keeping needed items within reach, maintaining the bed in a low position, ensuring furniture was locked during care, and keeping the call light accessible. Despite these interventions, the resident experienced a fall resulting in a laceration to the right eyebrow that required sutures and an emergency room visit. On the night of the incident, a CNA was providing incontinence care to the resident, who was positioned on his side in bed. The CNA left the resident briefly to retrieve additional linen from a cart located by the door, leaving the resident unattended. During this time, the resident fell from the bed. The CNA reported that the bed was not in the lowest position but at about hip level, and no bed rails were in use. The resident was found on the floor, alert and oriented, with a wound on the right eyebrow and complaints of pain in both arms. The nurse on duty confirmed that the bed was waist high and that the resident had no bed rails. The nurse also stated that, for safety, the resident should have been placed on his back and the bed lowered before leaving the room, especially given the resident's quadriplegia. Interviews with facility leadership, including the DON and Administrator, revealed that staff are expected to ensure residents are left in a safe position before stepping away, which includes centering the resident in bed and lowering the bed. Both leaders agreed that, for a resident with quadriplegia, the safest position when left briefly would be on the back. Facility policies require individualized fall prevention interventions and safe positioning during care, but these were not consistently implemented in this case, leading to the resident's fall and injury.