Failure to Prevent Fall in Cognitively Impaired, Bedbound Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safety of a resident with severe cognitive impairment, impaired mobility, and multiple medical diagnoses, including metabolic encephalopathy, chronic kidney disease, weakness, and Alzheimer's disease. The resident was assessed as being at high risk for falls, with a care plan in place that included maintaining a clutter-free environment, monitoring and assisting with toileting needs, and ensuring call lights were within reach. Despite these interventions, the resident was found on the floor next to the bed in the early morning hours and was subsequently transferred to a general acute care hospital for evaluation following the fall. Interviews with facility staff revealed that the resident was bedbound and required full assistance for mobility, with staff noting the resident's dependence and inability to turn or get up independently. The staff could not recall the last time the resident was observed in bed prior to the fall. The facility's policies required assessment for fall risk and implementation of appropriate interventions, but the incident demonstrated a failure to provide adequate supervision and accident hazard prevention, resulting in the resident's fall and hospital transfer.