Failure to Prevent Accidents and Inadequate Fall Investigation
Penalty
Summary
A deficiency occurred when a resident who required transfers with a mechanical lift was not transferred safely, resulting in actual harm. The resident, with a history of morbid obesity, heart disease, and osteoporosis, was dependent on staff and a mechanical lift for transfers. During a transfer from a shower bed to her regular bed, the sling pad used with the mechanical lift broke, causing the resident to fall and sustain a lumbar vertebral compression fracture. Staff interviews and documentation revealed that the sling pad had visible signs of wear, including frayed and distressed straps, and had been improperly laundered in a commercial dryer, which contributed to the deterioration of the material. Despite warnings on the sling pad label and in the instruction manual to inspect for wear and avoid drying in a dryer, the facility had not replaced sling pads regularly or ensured proper inspection before use. Another deficiency was identified regarding the supervision and assistance provided to a second resident during bathing and in the investigation of multiple falls. This resident, with diagnoses including bipolar disorder, spinal stenosis, and Parkinsonism, was at risk for falls and required substantial assistance for bed mobility and bathing. On one occasion, the resident fell from bed while being left unattended by a CNA who had failed to lock the bed wheels. The incident report and staff interviews confirmed that the bed was left unlocked and the resident was left alone, leading to the fall. The facility's documentation did not show that a thorough investigation or formal education for the CNA was completed beyond immediate verbal instruction. Additionally, the facility failed to conduct thorough investigations into several other falls experienced by the same resident. Incident reports for multiple unwitnessed falls lacked critical information, such as the resident's location prior to the fall, whether safety interventions like a perimeter mattress or call light were in place or used, and whether the fall mat was present. The facility's fall prevention policy required post-fall assessments and documentation but did not provide specific guidance for comprehensive investigations. The lack of detailed investigation and documentation placed the resident at risk for further harm.