Failure to Implement and Document Fall Prevention and Safe Transfer Interventions
Penalty
Summary
The facility failed to ensure that accident hazards were minimized and that adequate supervision and assistive devices were provided to prevent accidents for multiple residents. One resident with vascular dementia and significant physical dependencies was care planned to have a perimeter mattress to reduce fall risk, but observations on multiple dates confirmed that the perimeter mattress was not in place. Staff interviews corroborated that the required equipment was not provided, despite the resident's high risk for falls and cognitive impairment. Another resident with severe cognitive impairment and a history of falls was care planned to have the bed in the lowest position and fall mats in place at all times. However, observations revealed the bed was in a high position and the fall mats were not in place, with no staff present to supervise. Staff interviews confirmed that the interventions were not implemented as required, and that staff were resistant to using the double fall mat due to its inconvenience. This resident had experienced multiple falls, and the lack of adherence to the care plan placed the resident at further risk. A third resident, also with severe cognitive impairment and a high risk for falls, experienced multiple unwitnessed falls. The care plan required a perimeter mattress and other interventions, but fall investigations did not consistently document whether these interventions were in place at the time of each fall. Additionally, the facility failed to consistently initiate and document neurological checks after unwitnessed falls, as required by facility policy. The DON confirmed that documentation was lacking and that fall investigations were incomplete. In another incident, a resident who required a mechanical lift for transfers was transferred by a CNA without the lift or a second staff member, resulting in a fall and bilateral femur fractures. The DON confirmed the improper transfer and resulting injuries.