Failure to Maintain Fall Interventions Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that fall risk and safety interventions were in place for a resident with a known history of falls from bed. The resident had severe cognitive impairment, required extensive assistance from two staff for bed mobility, and was identified as being at high risk for falls due to multiple medical conditions, including a cerebrovascular accident with left-sided hemiplegia, muscle contractures, and confusion. The resident's care plan included specific interventions such as keeping the bed in the lowest position and ensuring a fall mat was in place. On the day of the incident, a CNA left the resident's room to retrieve personal care supplies, leaving the bed in a high position and the fall mat leaned against the wall instead of being properly placed. During this time, the resident rolled out of bed and sustained a fall, resulting in a nondisplaced intertrochanteric fracture of the left femur. The resident was found on the floor by her bed, complained of hip pain, and was subsequently hospitalized for surgical repair of the fracture. The investigation confirmed that the required fall interventions were not in place at the time of the fall. Prior to this incident, the resident had a documented history of falls, including a recent fall from bed without injury. The care plan and fall risk assessments had identified the need for consistent implementation of fall prevention measures. However, staff failed to follow these interventions, directly leading to the resident's injury. Interviews with staff confirmed that the fall precautions were not maintained when the CNA left the room, and the incident was immediately reported to management.