Failure to Timely Implement and Maintain Fall Interventions
Penalty
Summary
A deficiency was identified when a resident with multiple psychiatric diagnoses, including borderline personality disorder, bipolar disorder, schizoaffective disorder, generalized anxiety disorder, and major depressive disorder, experienced a fall while attempting to transfer from a wheelchair to bed. The resident was assessed as moderately cognitively impaired and had a history of two or more falls since the last MDS assessment. The care plan included interventions such as anti-roll backs for the wheelchair and the use of nonskid footwear, but these interventions were not consistently implemented. On the day of observation, the resident was found sitting in a wheelchair without anti-roll backs, and was wearing fluffy socks instead of nonskid socks while transferring herself from the wheelchair to the bed. The resident expressed confusion and frustration about her wheelchair being switched out by staff for maintenance to apply anti-roll backs, and refused assistance from the ADON during the transfer. The lack of timely implementation of fall interventions and failure to ensure interventions were in place contributed to the deficiency.