Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement fall prevention interventions for a resident identified as high risk for falls. The resident, who had a history of falls, dementia, severely impaired cognition, and was always incontinent, required substantial to maximal assistance with transfers, mobility, and toileting. On the night of the incident, the resident was found on the floor near the bathroom after an unwitnessed fall and was later diagnosed with a left femur fracture. The resident had been attempting to go to the bathroom unassisted. Certified Nursing Assistant (CNA) staff assigned to the resident's care during the shift reported being unfamiliar with the resident's fall risk status and did not review the fall binder that night. The CNA also could not recall if toileting or incontinence care was provided or documented for the resident during the shift. Review of CNA documentation for that shift showed no entries for bladder and bowel elimination or toilet transfers for the resident. The facility's policies required regular checks and care for incontinent residents and specific fall prevention interventions for those at high risk, including visual checks and assistance with care needs. Interviews with staff confirmed the importance of providing regular incontinence care and supervision to prevent residents from attempting unsafe self-transfers. The lack of staff awareness of the resident's fall risk, failure to provide and document required care, and absence of supervision contributed to the resident's ability to attempt to transfer independently, resulting in a fall and serious injury.