Failure to Provide Adequate Supervision and Proper Use of Fall Prevention Devices
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of repeated falls, epilepsy, and lack of coordination did not receive adequate supervision and proper use of fall prevention devices as outlined in their care plan. The resident, who was dependent on staff for activities of daily living and enrolled in hospice care, was transferred to a drop seat wheelchair by a nursing assistant. However, the staff member failed to engage the drop-down seat into the reclining position, which was a required intervention to prevent the resident from falling forward. As a result of this omission, the resident fell forward out of the wheelchair in the dining room, sustaining a laceration to the left forehead that required hospital intervention for bleeding control and stitches. The incident was unwitnessed, and the facility's incident reporting log confirmed the fall and injury. Staff interviews revealed that the required post-fall procedures were followed after the incident, but the administrator acknowledged that the investigation into the event had not been completed at the time of the survey.