Failure to Implement Fall Prevention Interventions During Resident Care
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions for a resident with cerebral palsy, muscle weakness, and significant mobility impairments. The resident, who required extensive assistance with bed mobility and used a wheelchair, had a care plan in place specifying that the bed should be kept in the lowest position at all times except during care. Despite this, during a bathing routine, the nurse assistant left the resident unattended on the bed, which was not in the lowest position, while stepping away to request cream for skin care. As a result, the resident slid off the bed and struck her head on the nightstand, sustaining pain and injury. Interviews with staff confirmed that the bed was not lowered before the nurse assistant left the resident, contrary to the care plan and facility policy. The Director of Nursing acknowledged that the bed should have been lowered before the staff member left the resident unattended, as direct care was no longer being provided at that moment.