Failure to Prevent Accidents and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure adequate care and supervision to prevent accidents for two residents. In the first case, a resident with Alzheimer's disease, dementia, and mobility issues sustained a large, deep wound to the left lower leg during a transfer and required hospital evaluation and sutures. Documentation showed the resident required assistance and the use of a walker and gait belt for transfers, as outlined in the facility's Safe Resident Handling/Transfer Equipment policy. However, staff interviews revealed that the transfer was performed without a walker or gait belt, and the staff member assisting was not assigned to the resident and did not remove the resident's clothing, which delayed the discovery of the injury. In the second case, another resident with dementia, muscle weakness, a history of falls, and severe cognitive impairment experienced an unwitnessed fall resulting in a left hip fracture. Prior to this, the resident had a bruise on the left bicep, and a Change in Condition evaluation was completed, but no new fall prevention interventions were implemented as required by the facility's Falls Management policy. Staff interviews confirmed that after the unwitnessed fall and identification of the bruise, no additional interventions were put in place to address the resident's increased fall risk. Both incidents demonstrate a failure to follow established facility policies for safe resident handling and falls management. The lack of proper transfer techniques and failure to update care plans with new interventions after a fall directly contributed to the residents' injuries.