Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions for a resident with a history of rolling out of bed. The resident, who had diagnoses including autism, anxiety, and developmental disorder, was care planned to have a fall mat on the left side of the bed, the bed kept in the lowest position when not providing care, and frequently used items including the call light within reach. Despite these interventions, a CNA left the resident unattended with the bed raised to hip level while retrieving a lift, during which time the resident rolled off the bed and sustained a femur fracture. The resident's care plan and facility policy required supervision and specific interventions to minimize fall risk, but these were not followed at the time of the incident. Observations and interviews confirmed that the call light was not within the resident's reach, contrary to care plan directives. The CNA involved acknowledged leaving the bedside with the bed elevated, and the Nursing Home Administrator confirmed the resident's history of rolling out of bed. Facility documentation and staff interviews further substantiated that the required fall prevention measures were not consistently implemented, directly leading to the resident's fall and injury.