Failure to Implement Fall Prevention Care Plan During Transfer
Penalty
Summary
The facility failed to implement care plan interventions designed to prevent falls for a resident with a history of impaired gait, balance issues, and a high risk for falls. The resident, who was cognitively intact and required substantial assistance with transfers, was admitted with diagnoses including abnormalities of gait and mobility, lack of coordination, and a need for assistance with personal care. The care plan for this resident included interventions such as adapting the environment for safety, anticipating and meeting the resident's needs, and assisting with all transfers or ambulation. Despite these interventions, on the date of the incident, the resident was not properly positioned in the wheelchair after being transferred from the toilet by a CNA, which resulted in the resident sliding off the wheelchair and falling to the floor. Interviews and documentation confirmed that the CNA did not ensure the resident was seated properly in the wheelchair before moving it, and both the LVN and DON acknowledged that the resident was sitting close to the edge of the seat at the time of the fall. The facility's policies emphasized the importance of individualized, resident-centered safety interventions and the implementation of care plan measures to prevent accidents. However, these measures were not followed during the transfer, directly leading to the fall event. The resident did not sustain injuries as confirmed by subsequent x-rays.