Failure to Reassess Falls and Ensure Safe Use of Heating Pad
Penalty
Summary
The facility failed to comprehensively reassess and implement appropriate person-centered interventions following multiple falls for two residents, and did not properly assess or document the use of a heating pad for another resident. One resident with mild cognitive impairment and a history of falls experienced several unwitnessed falls, some resulting in emergency room visits and injuries, often due to her feet becoming entangled in oxygen tubing. Despite repeated incidents and the resident's own request for shorter tubing, the care plan was not updated with new interventions, and staff continued to rely on the same measures such as keeping the call light and walker within reach and providing verbal reminders, which were acknowledged by staff as insufficient. Another resident with severe cognitive impairment and a history of wandering and falls also experienced multiple falls, including incidents where she was found on the floor or had fallen out of bed. Although the care plan included interventions such as motion detectors, nonstick footwear, and hourly rounding, documentation of new or revised interventions following each fall was lacking. Staff interviews confirmed that reminders to ask for assistance were ineffective due to the resident's dementia, and that the facility needed to improve documentation and analysis of falls to ensure interventions were appropriate and updated. Additionally, a resident was observed using a heating pad in her room without a provider order, care plan documentation, or evidence that the device had been checked for safety compliance. Staff were unaware of the heating pad's presence, and the device was found to have an ungrounded two-prong cord, contrary to facility policy requiring grounded plugs and automatic shut-off features. The lack of assessment and documentation for the heating pad's use, as well as failure to ensure it met safety requirements, constituted a deficiency in preventing accident hazards.