Failure to Maintain Equipment and Implement Fall Precautions Leads to Resident Injury
Penalty
Summary
A resident with multiple diagnoses, including heart disease, hypertension, congestive heart failure, psychotic disorder, depression, and anemia, was identified as being at risk for falls due to impaired mobility and cognitive impairment. The care plan required the use of a fall mat, a bed bolster, and monitoring of these interventions every shift. However, observations revealed that the bed bolster was missing, and fall mats were placed on the floor rather than next to the bed. Documentation showed that the bed bolster was not listed on the Treatment Administration Record (TAR) for August, and there was no evidence of monitoring from the beginning of the month through the date of observation. The resident experienced a witnessed fall in the shower room, resulting in a forehead injury and subsequent transfer to the hospital. The post-fall evaluation identified that the shower bed was broken, which contributed to the fall. Staff interviews confirmed that the shower bed moved unexpectedly during care, leading to the resident's fall. The facility's policy required identification and mitigation of hazards, but the broken equipment and lack of proper fall precautions were not addressed, resulting in the incident.