Failure to Provide Required Fall Prevention Measures for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision was provided to prevent accidents. Specifically, a resident with a significant history of falls and multiple risk factors—including cerebrovascular disease, seizures, psychotic disorder, muscle weakness, lack of coordination, and cognitive impairment—did not have a floor mat at the bedside as required by his care plan. The care plan, updated prior to the incident, explicitly included interventions such as keeping the bed in a low position and placing a fall mat at the bedside when the resident was in bed. On the day of the incident, the resident was found to have fallen out of bed, sustaining a laceration and hematoma to the left forehead. Staff interviews revealed that the resident had recently been moved to a new room, and the floor mat was not present at the bedside at the time of the fall. CNAs and nursing staff acknowledged that the resident was a known fall risk and that the absence of the floor mat was contrary to established fall prevention protocols. The incident was unwitnessed, and the resident was later sent to the hospital for evaluation, where imaging confirmed a subcutaneous hematoma but no acute intracranial injury. Multiple staff, including CNAs, LVNs, the ADCO, and the DCO, confirmed that fall prevention measures such as floor mats, low beds, and accessible call lights were standard practice for residents at risk of falls. The failure to have the floor mat in place was recognized by staff and administration as a lapse in following the resident's care plan and facility policy. The facility's own policy required that fall prevention programs be implemented and reviewed after any fall, and that interventions be documented and updated in the plan of care.