Failure to Prevent Accident Hazards and Implement Appropriate Fall Interventions
Penalty
Summary
The facility failed to ensure that areas were free from accident hazards and that adequate supervision and interventions were provided to prevent accidents for multiple residents. For one resident with a history of stroke and left-sided weakness, staff propelled his wheelchair without ensuring his foot was on the foot pedal, resulting in his foot becoming caught under the wheelchair and causing pain. Staff acknowledged that the resident's foot did not always stay on the pedal, and it was the facility's expectation that foot pedals be used during transport, but there was no policy in place to guide this practice. Another resident with severe cognitive impairment and lower extremity weakness was transported in a wheelchair without foot pedals, causing his feet to skim the floor. Staff stated that the wheelchair lacked foot pedals because the resident sometimes propelled himself, but also confirmed that foot pedals should be used when staff are propelling residents. Again, there was no facility policy provided regarding the use of foot pedals during wheelchair transport. Additionally, the facility failed to implement appropriate interventions following a fall for a resident with intellectual disability and severe cognitive impairment. After a non-injury fall, the care plan was updated to include reminders for the resident to use the call light, despite staff and administrative acknowledgment that such reminders were not appropriate for residents with low cognitive function. The facility's falls management policy required care plans to be reviewed and revised with each fall and for new interventions to be implemented, but this was not consistently done.