Failure to Ensure Functioning Safety Equipment and Post-Fall Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's enabler bar was functioning properly, did not complete a thorough assessment after the resident experienced a fall, and did not implement fall interventions for a resident identified as high risk for falls. The resident, who had diagnoses including Parkinson's disease and a recent vertebral fracture, was admitted with a history of falls and was assessed as being at risk for further falls. Upon admission, bilateral side rails were indicated for safety, but the left bedside rail was found to be stuck down and not functioning. Staff interviews revealed that the enabler bar could not be fixed due to lack of tools, and responsibility for ensuring equipment functionality was shared among the Admissions Coordinator, CNAs, and maintenance staff. Following the resident's fall, the facility's policy required post-fall assessments every shift for 72 hours, but no such assessments were documented in the electronic health record for the day of the fall. Additionally, the resident's care plan, which identified the risk for falls, did not include any fall interventions until the day after the incident. The DON was unable to explain the lack of post-fall assessments. The facility's own policy outlined specific assessment and documentation requirements after a fall, including monitoring for injury, changes in cognition, and neurological status, none of which were documented as completed for this resident.