Failure to Implement and Monitor Fall Prevention Interventions and Safe Transfer Techniques
Penalty
Summary
The facility failed to implement and monitor fall prevention interventions as care planned for multiple residents. For one resident with rheumatoid arthritis, diabetes, and a stage four pressure ulcer, a bed alarm was in use, but there was no documentation that its efficacy was monitored on an ongoing basis or that it was used to assess the resident's patterns and routines. The resident expressed dissatisfaction with the alarm, stating it was loud and frequently activated. The DON confirmed that alarm use was not routinely monitored for effectiveness and that there was no documentation supporting the intended use of alarms for pattern assessment. Another resident with Alzheimer's disease and multiple psychiatric diagnoses had a chair alarm attached to her wheelchair following a recent fall. However, there was no evidence in the clinical record that the alarm's effectiveness was regularly reviewed or that it was used to assess the resident's routines. The DON acknowledged the lack of routine monitoring and documentation for alarm use. Additionally, a third resident with a history of stroke and heart failure was observed with a chair pad alarm that was not connected to the alarm box, rendering it nonfunctional until a nurse reconnected it during the observation. In a separate incident, two CNAs transferred a resident with severe cognitive impairment and high fall risk from a wheelchair to bed without using a gait belt, contrary to facility policy and the resident's care plan. The CNAs lifted the resident by his arms and pants, and when questioned, one CNA admitted forgetting to use the gait belt. The facility's policy requires the use of appropriate techniques and devices, such as gait belts, for safe resident transfers, and staff are expected to be trained in their use.