Failure to Implement Fall Prevention Interventions and Ensure Safe Transfers
Penalty
Summary
The facility failed to implement appropriate interventions to prevent falls and ensure resident safety for five out of seven residents reviewed for accidents. In multiple instances, staff did not use required equipment such as foot pedals on wheelchairs or mechanical lifts during transfers, despite care plans and physician orders specifying their necessity. For example, one resident with a history of falls, dementia, and a left artificial hip joint was transferred from a shower to a bed without the use of a mechanical lift or wheelchair foot pedals, resulting in a fall that caused abrasions and a skin tear. Staff interviews confirmed that the required interventions were not followed at the time of the incident. Another resident with progressive neurological disease, severe obesity, and osteoporosis experienced two falls while ambulating with staff assistance. In both cases, the staff member left the resident unattended or did not maintain proper supervision, contrary to the care plan interventions that required the use of a gait belt and close assistance. The falls were attributed to lower extremity weakness, and the care plan was updated only after the incidents occurred. Staff interviews revealed that the CNA recognized the error in leaving the resident alone, and the DON acknowledged that the required supervision was not provided. Additional observations showed residents being transported in wheelchairs without foot pedals, resulting in their feet dragging or being positioned unsafely. In one case, a resident with dementia and recent fractures was pushed in a wheelchair without foot pedals, despite the care plan instructing staff to encourage their use. Another resident with repeated falls and severe cognitive impairment slid out of a wheelchair when their feet hit the floor during transport, as foot pedals were not in place. Staff interviews and documentation confirmed that the facility's fall management policy was not consistently followed, and interventions to prevent accidents were not reliably implemented.