Failure to Identify and Address Electric Lift Chair as Fall Hazard
Penalty
Summary
The facility failed to identify an electric lift chair as a fall hazard, did not develop or implement appropriate post-fall interventions, and did not thoroughly investigate falls for a resident with severe cognitive impairment and a high risk for falls. The resident required substantial to maximal assistance for mobility and had a care plan that included interventions such as a silent recliner alarm, nonskid mat, and standby assist for transfers. Despite these interventions, the resident experienced multiple unwitnessed falls from the electric lift chair, with documentation indicating that the chair alarm was not properly connected and the lift chair remote was within the resident's reach. After one fall, the resident was found on the floor in front of the recliner, which was in a forward tilt position, and was unable to recall the incident. There was no documentation of post-fall interventions for this event. In a subsequent fall, the resident was again found on the floor in front of the electric lift chair, which was fully elevated, and the alarm was not plugged in to activate the call light. The investigation did not identify the root cause of the fall, did not document whether the nonskid mat was in place, and did not assess the lift chair as a potential hazard. The facility's staff interviews confirmed uncertainty about alarm function checks and the placement of the chair remote, and the facility lacked a policy or assessment process for the use of electric lift chairs. The resident sustained a nondisplaced left femoral neck fracture requiring surgical repair following the second fall and subsequently passed away. The facility's fall management policy required individualized fall prevention plans and monitoring of interventions, but there was no evidence that the facility re-evaluated or changed interventions after repeated falls, nor that the electric lift chair was considered as a contributing factor.