Failure to Implement Fall Prevention Interventions and Safe Equipment Use
Penalty
Summary
The facility failed to implement and maintain effective interventions to prevent accidents for a cognitively impaired male resident with a high risk for falls. The resident, who had diagnoses including unspecified dementia with psychotic disturbance and was dependent on staff for mobility and personal care, was care planned to have a bed/chair alarm to alert staff when attempting to get up unassisted. However, on multiple occasions, the alarm was either not functioning, not in place, or not heard by staff, resulting in unwitnessed falls. Staff interviews and observations confirmed that the bed alarm was left in the reclining chair when the resident was put to bed, and at one point, the alarm was not working due to dead batteries. The resident was unable to use the call light and was known to become agitated when wet or soiled, increasing his risk of attempting to get up unassisted. Additionally, the facility failed to follow the manufacturer's safety recommendations for the use of the reclining chair during transport. The resident fell out of the reclining chair while being transported to the patio by a CNA, who was unable to see the resident while pulling the chair backwards over a door threshold. The manufacturer's manual specified that outdoor use of the chair should only occur under strict supervision and with a second caregiver when moving over uneven surfaces, which was not followed during the incident. Staff interviews indicated that only one CNA was present during the transport, and the resident made sudden movements that were not anticipated or prevented. As a result of these failures, the resident experienced at least two falls, one of which resulted in a large bruise on the left side of his neck and jaw. Documentation and interviews confirmed that the bruise was likely related to the fall, and the resident was found on the floor on more than one occasion. The facility's own fall policy required assessment, implementation, and reevaluation of interventions, but these were not consistently carried out, leading to the resident's injuries.