Failure to Implement Fall Prevention Interventions and Supervision
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented for a resident with dementia, a history of falls, and chronic kidney disease. The resident was dependent on staff for transfers and used a wheelchair for mobility. The care plan specified that the resident's reclining wheelchair should be locked and tilted back when not eating, and that reminder signs should be in place to ensure these interventions were followed. Despite these measures, the resident experienced a fall in the dining area after pushing herself away from the table, resulting in a head laceration and pain, and required transfer to the emergency room for evaluation. Family interview and record review indicated ongoing concerns about inadequate supervision in the dining area, with insufficient CNA or nurse presence and reliance on dining staff. Documentation revealed that at the time of the fall, only one wheel of the wheelchair was locked, and the resident was able to push herself away from the table, leading to the incident. The facility's fall prevention policy required individualized interventions and supervision, but these were not effectively implemented for this resident, resulting in the fall and injury.