Failure to Implement Fall Prevention Interventions Leads to Resident Fall
Penalty
Summary
The facility failed to implement interventions consistent with a resident's needs and current professional standards of practice to eliminate the risk of a fall for one resident. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left side, unsteadiness on feet, muscle weakness, and cognitive symptoms, was identified as a fall risk and required prompt response to all requests for assistance. On the day of the incident, the assigned CNA was taking vital signs and meal orders and instructed the resident to wait after he requested something. The CNA left to attend to other residents and returned within five minutes, at which point the resident was found on the floor with a bump on his head. The resident was known to require frequent redirection and assistance, and his care plan included interventions such as frequent reminders to use the call light, bed in the lowest position, safety floor mats, and frequent rounds. Staff interviews revealed that the CNA prioritized routine tasks over the resident's immediate request, and the nurse was unaware that the resident had asked for assistance. The DON acknowledged that not fulfilling the resident's needs could lead to a fall, emphasizing that attending to residents' needs should be a priority. Documentation confirmed the resident's fall risk status and the need for prompt assistance. The facility's fall prevention policy called for an interdisciplinary approach and appropriate interventions to reduce fall risk, but these were not effectively implemented in this instance, resulting in the resident sustaining a fall.