Failure to Maintain Accident-Free Environment and Implement Fall Interventions
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not implement care-planned fall interventions for a resident with significant cognitive and physical impairments. The resident, who was severely cognitively impaired, Spanish-speaking, and had diagnoses including hemiplegia, hemiparalysis, and muscle weakness, was care planned for a low bed position to reduce fall risk. However, multiple observations revealed the resident's bed was not kept in a low position as required. Staff interviews confirmed a lack of awareness regarding the care plan intervention for a low bed, and the resident reported that the bed was only recently placed in a low position, indicating the intervention was not consistently followed. Additionally, after the resident experienced a fall during personal care, the facility did not conduct a thorough post-fall investigation to determine the cause. Documentation of the incident was insufficient, with staff unable to clarify whether language barriers or lack of interpreter support contributed to the fall. The Director of Nursing acknowledged that the incident report lacked adequate detail and that staff did not ask enough questions to identify the root cause. The facility's policy required a comprehensive post-fall investigation and revision of interventions, but this was not completed as outlined.