Failure to Follow Fall Prevention Care Plan Results in Resident Injury
Penalty
Summary
A certified nursing aide (CNA) failed to follow a resident's comprehensive care plan for fall prevention, resulting in a significant accident. The resident, who had diagnoses including dementia, unsteadiness, muscle weakness, and impaired cognition, required substantial assistance for transfers and was at high risk for falls. The care plan specified interventions such as staff assistance with transfers, use of a fall mat, bed in the low position, and a perimeter mattress to define the bed's edges. Despite these directives, the CNA left the resident seated on the edge of the bed unsupervised while retrieving an item, during which time the resident attempted to transfer independently and fell to the floor. Following the fall, the resident was assessed and found to have pain in the torso and lower extremities. Emergency department evaluation revealed acute, displaced fractures of both femurs, with the left femur showing a comminuted fracture and the right femur an acute displaced oblique fracture. The resident required surgical intervention and hospitalization due to the severity of the injuries. The clinical record and staff interviews confirmed that the resident had severe cognitive deficits and did not remember needing assistance with transfers, further emphasizing the necessity of staff supervision as outlined in the care plan. Documentation indicated that the CNA had moved floor mats to position a wheelchair for transfer but left the resident unattended, directly contravening the care plan's requirement for one-person assistance during transfers. The facility's fall management policy aimed to maintain a hazard-free environment and implement preventative measures, but in this instance, the failure to provide adequate supervision and adhere to the care plan led to the resident's fall and subsequent injuries.