Failure to Implement Fall Precautions and Supervision for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure a newly admitted resident received adequate supervision and accident prevention measures. The resident, who had a history of cerebral edema, nontraumatic intracerebral hemorrhage, acute respiratory failure with hypoxia, and significant mobility and cognitive impairments, was admitted with hospital discharge orders to be placed on fall precautions. However, these orders were not implemented upon admission, and no fall precautions were entered into the resident's order summary. The baseline care plan was not developed or implemented within 48 hours of admission to address the resident's high fall risk status, and the admission assessment and baseline care planning were incomplete. Staff did not have adequate knowledge or access to the resident's care plan, and the Kardex system, which should have provided key safety and care information to direct care staff, was not updated to reflect the resident's fall risk or necessary interventions. Interviews with nursing and CNA staff revealed that fall risk information was not consistently documented or communicated through the Kardex, and staff relied on verbal reports rather than written care plans or Kardex entries. The admitting nurse believed that checking a high fall risk box would automatically update the care plan and Kardex, but was unaware of how to verify or access these documents. As a result of these systemic failures, the resident was left unsupervised in her room and experienced a fall from her wheelchair, hitting her head and exhibiting pain and nystagmus, which required transfer to an acute care hospital. The facility's failure to implement fall precautions, develop and communicate a baseline care plan, and ensure staff competency in using the Kardex system directly contributed to the incident. The deficiency was identified as Immediate Jeopardy due to the likelihood of serious adverse outcomes.
Removal Plan
- Physician notification by licensed nurse of the fall.
- Responsible party notified by licensed nurse of the fall.
- Resident sent to the hospital.
- Director of Nursing Services/Assistant Director of Nursing Services/Registered Nurse Assessment Coordinator conducted an audit of all residents to review Fall Risk Assessments and care plans for person-centered interventions.
- Director of Nursing Services and administrative nurses provided education by way of in-service to nurses on Abuse Neglect, Residents Rights, initiating interventions to prevent a fall, and Fall Prevention Guidelines.
- All admissions will be reviewed during clinical connect meeting to ensure interventions are initiated to prevent a fall for those residents identified as a fall risk.
- Director of Nursing Services/Administrative Nursing is responsible for ensuring compliance and oversight of monitoring and education.
- Direct care team educated on review of the Kardex before providing care to ensure proper assistance and interventions are utilized according to the resident's need and adherence to the resident's plan of care.
- Reporting any concerns or inaccuracies to the charge nurse/licensed nurse for additional direction prior to care provided.
- Licensed nurses will initiate interventions to prevent falls for those identified as a fall risk upon admission and/or as indicated.
- All nursing staff will receive the in-service prior to working next shift.
- All newly hired nursing staff will receive in-service training prior to assuming shift responsibility during orientation process.
- All agency nursing staff will receive in-service training prior to assuming shift responsibility.
- Director of Nursing Services/Administrative nurses conducted skills validation of all nurse aides in training and certified nurse assistants of accessing the Kardex.
- No licensed nurse, nurse aides in training, or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex.
- Community will ensure administrative nursing staff provide in-service/education prior to team members working their assigned shift; these trainings will also be conducted with new hires.
- Director of Nursing Services/administrative nurses provided education to direct care team on Fall Prevention Guidelines/Abuse Neglect/Residents Rights, Kardex Use prior to providing care.
- Director of Nursing Services/Administrative Nurses is responsible for ensuring compliance and oversight of monitoring and education.
- Licensed nurse will initiate interventions to prevent falls upon admission and as indicated for those at risk for falls.
- Director of Nursing Services/Administrative nurses conducted skills validation to direct care staff on accessing the Kardex.
- Community will ensure all staff on leave/agency/PRN staff/new hires are in-serviced prior to working their shift.
- No licensed nurse, certified medication aide, or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex.
- Director of Nursing Services/Administrative nurses will review Admission/Readmission Assessments in the Daily Clinical Connect meeting to ensure residents at risk for falls have interventions in place and documented using a monitoring tool.
- Administrator/Director of Nursing Services will conduct random audits of care plans to validate fall intervention care plans are in place.
- Director of Nursing Services/Administrative Nurses/Designee will conduct random skills validations regarding Kardex use to ensure direct staff is compliant with the use of the Kardex.
- All findings will be reported to the QAPI committee during monthly meeting until there is compliance observed during observations.
- Additional education will take place based on needs observed during this process.