Failure to Implement Fall Precautions for Resident with History of Falls
Penalty
Summary
A deficiency occurred when a resident with a history of falls and cognitive impairment was repeatedly observed seated in a wheelchair without anti-lock brakes in place, despite care plan interventions and physician orders requiring their use. The resident, diagnosed with hypertension, vascular dementia, and delusional disorder, required substantial to maximal assistance with bed mobility and transfers. Observations over several days showed the resident in various facility areas without the required anti-lock brakes on the wheelchair. Documentation indicated that staff had signed off that the brakes were in place every shift, but interviews revealed that the resident's wheelchair had been changed in recent months and the anti-lock brakes were not transferred to the new chair as required.