Failure to Assess Geri-Chair Use Leads to Accident Hazard
Penalty
Summary
The facility failed to properly assess a resident for the use of a Geri-chair, which resulted in a deficiency related to accident hazards and inadequate supervision. The facility's Fall Management policy requires that each resident's risk for falls be evaluated and that appropriate interventions, including assistive devices, be implemented based on interdisciplinary assessment. However, for a resident with a diagnosis of Myasthenia gravis and a history of unsteady gait and fall risk, there was no documented therapy assessment for the use of a Geri-chair, nor was its use included in the resident's care plan as a fall prevention measure. Multiple staff interviews confirmed that the resident was observed in a Geri-chair on several occasions, and the resident's family member reported frequent falls. The Director of Rehabilitation and the RN supervisor both stated that therapy should assess residents for Geri-chair use, and expressed concerns that using a Geri-chair for a resident who is able to stand could pose an accident hazard. Despite this, the resident was placed in a Geri-chair without a documented therapy assessment or interdisciplinary team involvement. Documentation reviewed, including comprehensive nursing assessments and the care plan, did not reflect any evaluation or plan regarding the Geri-chair as an intervention. The DON indicated that the decision to use the Geri-chair was made by nursing staff for comfort, rather than based on a formal assessment. This lack of proper assessment and care planning for the use of the Geri-chair created the potential for falls and injuries for the resident.