Failure to Implement Care Planned Fall Interventions Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that care planned interventions to reduce the risk for falls were followed for two residents, resulting in actual harm to one resident who sustained a vertebral fracture. One resident, who had a history of dementia, thoracic vertebrae fractures, muscle weakness, and osteoporosis, was assessed as high risk for falls and required assistance with mobility and transfers. Her care plan specified the use of a wheelchair for transport and the need for extensive assistance from one to two staff members during transfers. Despite these interventions, a nursing assistant attempted to ambulate the resident without a transfer belt, contrary to the care plan and family wishes, resulting in a fall and subsequent T12 compression fracture. The nursing assistant admitted to not reviewing the care plan and not being trained on it prior to the incident. Another resident with diagnoses including traumatic subdural hemorrhage, Alzheimer's disease, multiple fractures, and repeated falls was also identified as high risk for falls. His care plan required two caregivers for all transfers and ambulation, use of slip grip in his wheelchair and recliner, and other specific interventions. Despite these directives, the resident experienced multiple falls, some unwitnessed, including incidents where the slip grip was not in place and the resident was found on the floor. Staff interviews revealed a lack of awareness of the care plan interventions, with some staff unsure where to find the information or not realizing interventions were listed on the care guide. Observations and interviews confirmed that care planned fall interventions were not consistently implemented for both residents. Staff failed to use required safety equipment, such as transfer belts and slip grips, and did not always follow the specified level of assistance for transfers and ambulation. Documentation and staff statements indicated that care plans and care guides were not adequately reviewed or followed, contributing to repeated falls and injury.