Failure to Implement Fall Prevention and Safe Transfer Interventions
Penalty
Summary
The facility failed to implement appropriate fall prevention interventions and ensure safe transfer practices for two residents identified as being at risk for falls. One resident, who had diagnoses including cellulitis, unsteadiness of feet, abnormal gait, reduced mobility, and morbid obesity, required partial to moderate assistance for transfers. On the day of the incident, a CNA assisted the resident to the bathroom and instructed her to hold the grab bar and stand. As the resident attempted to stand, she lost her balance and fell. The CNA did not use a gait belt during the transfer, contrary to facility policy and the resident's care requirements. The resident sustained a right ankle fracture, which was later confirmed by X-ray and required surgical intervention. Interviews with staff and the DON confirmed that a gait belt should have been used and that the injury likely resulted from the fall. Another resident with impaired cognition, dementia, and a moderate risk for falls was observed in bed with fall mats stacked against the wall rather than positioned next to the bed as required by her care plan and physician orders. The bed was also not in its lowest position, further increasing the risk of injury from a potential fall. Multiple observations confirmed that the fall mats were not in place during different times, and staff interviews indicated awareness that the mats should be next to the bed when the resident is in it. Record review showed that both residents had documented fall risks and specific interventions ordered and care planned, such as the use of gait belts for transfers and placement of fall mats and low bed positioning. Despite these documented interventions, staff failed to consistently implement them, resulting in a fall with injury for one resident and unsafe conditions for another.