Failure to Prevent Accidents and Update Care Plans After Falls
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, a cognitively intact female with quadriplegia and contractures, was inappropriately transferred by a single CNA using a manual transfer instead of the required two-person mechanical lift. The CNA was unfamiliar with the resident, did not receive a proper handoff report, and did not check the Kardex for transfer instructions, resulting in the resident falling and sustaining a right ankle fracture. Another resident with a history of repeated falls, dementia, and osteoarthritis was admitted following a fall and fracture. After a subsequent fall with a major injury (left femur fracture), the facility failed to update the care plan with new interventions to address the increased fall risk. Although interventions such as bed in lowest position, fall mat, and alarms were documented in incident reports, these were not consistently included in the care plan or implemented. The resident experienced two additional falls, with documentation showing that interventions like fall mats and alarms were either not in place or not functioning as intended at the time of the incidents. Interviews with the DON confirmed that the care plans were not revised to include new interventions after significant falls, and that interventions listed in incident reports were not always reflected in the care plan or implemented. The lack of proper communication, failure to follow established transfer protocols, and inadequate updating and implementation of fall prevention interventions contributed to the residents' injuries.