Failure to Implement Fall Prevention and Safe Transfer Protocols
Penalty
Summary
The facility failed to ensure the safety of residents at risk for falls by not implementing care plan interventions, responding to call lights in a timely manner, and conducting timely intermittent observations. One resident with dementia and a history of repeated falls was not provided with required fall prevention measures such as Dycem under the mattress, and was left unattended for extended periods despite activating the call light and exhibiting restless behaviors. Video evidence showed the resident was not repositioned or checked on for several hours, resulting in multiple falls from bed. Staff also failed to use the mechanical lift with the required two-person assistance, as a hospice aide transferred the resident alone, contrary to physician orders and facility policy. Two other residents with quadriplegia and significant ADL needs were not provided with the required level of assistance during care. In both cases, a single CNA left the resident unattended while turned on their side during care, resulting in falls from bed. The care plans and Kardex for these residents specified the need for two-person assistance for mobility and toileting, but this was not followed. Staff interviews confirmed that only one aide was present during the incidents, and that the residents were dependent on staff for care due to their conditions. Additionally, the facility failed to complete required post-fall assessments for a resident who sustained minor injuries after a fall outside the building. Although the fall was witnessed and the resident was assessed for injuries, the pain assessment and fall assessment forms were not completed as required. These deficiencies were verified through record review, staff interviews, and facility policy review, affecting multiple residents with varying degrees of cognitive and physical impairment.