Failure to Implement Fall Prevention and Supervision Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate care planned interventions to prevent accidents for two residents. One resident with a history of dementia, multiple fractures, unsteadiness, and cognitive deficits was care planned for fall prevention measures, including keeping the bed in a low position, using a fall mat, ensuring the call light was within reach, and maintaining a hazard-free environment. Despite these interventions, the resident experienced an unwitnessed fall in the hallway, was found sitting on the floor, and later was diagnosed with a closed fracture of multiple pubic rami. Observations after the fall revealed that the fall mat was not consistently placed next to the bed as required, and the wheelchair was not within reach. The resident was also observed unsupervised in the dining room, attempting to pick up items from the floor without staff present, despite her impulsiveness and cognitive impairment. Another resident with a history of stroke, right-sided paralysis, muscle weakness, and reduced mobility was care planned for two-person assistance with transfers and ambulation, and the use of a gait belt for safety. During an observed transfer, a CNA assisted the resident from the wheelchair to the bed without using a gait belt and did not utilize the prescribed walker. The resident was prompted to hug the CNA for support during the transfer, and the wheelchair was placed out of reach afterward. The facility's policy and staff interviews confirmed that a gait belt should be used for all transfers involving residents who are weak or unsteady. The facility's fall prevention program required that residents at risk for falls receive care and services according to their assessed risk, and that interventions be monitored for effectiveness and revised as needed. However, direct observations and interviews indicated that care planned interventions were not consistently implemented for both residents, resulting in a fall with injury for one and the potential for harm for the other.