Failure to Meet Professional Standards in Fall Management and Response
Penalty
Summary
The facility failed to ensure that two residents received services that met professional standards of quality, as evidenced by documentation, staff interviews, and review of facility policies. One resident was admitted with multiple diagnoses including abnormal gait, muscle weakness, and a history of falls and fractures. After experiencing a fall, the resident complained of severe back pain and requested to be sent to the emergency room. Despite the complaint of severe pain following a fall and a history of lumbar fracture, the resident was sent to the hospital via non-emergent transportation, resulting in a significant delay. Staff interviews revealed that both the DON and ADON acknowledged that severe back pain after a fall should have prompted an emergent transfer, and the nurse involved stated that an emergency call would be appropriate if a resident had severe pain, indicating a possible fracture. The facility's policy required prompt assessment and following emergency personnel orders, which was not adhered to in this case. Another resident with diagnoses including cardiomyopathy, cerebral infarction, and hemiplegia was identified as a high fall risk upon admission and had a history of multiple falls with injuries. Despite physician orders for fall risk assessments every three months and after falls, there was no evidence of updated fall risk assessments following subsequent falls. Interviews with CNAs and LPNs revealed that direct care staff were not consistently informed of residents' fall risk status or specific preventative measures. New staff reported not receiving written or verbal information about which residents were at risk for falls, and there was no formal system in place to communicate this information. Observations confirmed that a resident's bed was kept in a high position, contrary to best practices for fall prevention, and staff were unaware of the resident's fall risk status. The DON stated that fall risk and preventative measures were supposed to be communicated verbally and through a CNA sheet, but both new and existing staff reported not receiving this information. The DON also admitted uncertainty about the existence of a formal fall management program. Facility policy required individualized interventions and regular fall risk assessments, but these were not consistently implemented or communicated to staff. The lack of updated assessments, failure to communicate fall risk status, and improper response to acute pain after a fall contributed to the facility's failure to meet professional standards of quality care for these residents.