Failure to Implement Care Planned Fall Interventions
Penalty
Summary
The facility failed to implement care planned interventions to reduce fall risk for two residents identified as being at risk for falls. One resident, with a history of vascular dementia, stroke, and right-sided weakness, was care planned to require two staff and a full body lift (MAXI lift) for all transfers. Despite this, a nursing assistant attempted to transfer the resident using a standing lift at the resident's request, resulting in the resident's right leg buckling and a fall to the floor. Multiple staff interviews confirmed that the transfer was not performed according to the care plan, and the resident's medical condition necessitated the use of the full body lift for safety. Another resident, with severely impaired cognition, heart failure, repeated falls, and on hospice care, was care planned to always have non-slip footwear and to be offered toileting at specific times, including before and after meals. Observations revealed the resident was found wearing slippery socks without grips and was not offered toileting as specified in the care plan. Staff interviews confirmed awareness of the care plan requirements, but these interventions were not consistently implemented during the survey period. Facility policies required that care plans be updated to reflect fall interventions and that staff use the care plan to guide daily care routines. Documentation and staff statements indicated that the care planned interventions for both residents were not followed, resulting in increased risk for falls and actual incidents of falls.