Failure to Implement Care-Plan Interventions for Fall Risk Resident
Penalty
Summary
A deficiency occurred when hospice staff failed to implement care-planned interventions for a resident identified as a fall risk. The resident, who had diagnoses of dementia, Parkinson's disease, and anxiety, was assessed as having severe cognitive impairment and required extensive assistance with bed mobility. The resident's care plan and physician orders specified the use of bilateral 1/4 side rail enablers while in bed to assist with mobility and increase safety. During personal care, a hospice nurse aide turned the resident in bed to assist with dressing and, while moving to the other side of the bed, did not realize the resident was holding onto the aide's pocket. The resident subsequently fell from the bed to the floor, sustaining lacerations to the left eyebrow and the back of the head, which required sutures and staples at a hospital. Documentation and investigation revealed that the side rail enablers were not utilized at the time of the incident, and the hospice aide was unaware of the care plan interventions and physician's orders regarding the use of side rails. Facility records and staff interviews confirmed that the required safety interventions were not communicated or implemented by the hospice staff, resulting in actual harm to the resident. The incident report also indicated that proper tools or equipment were not being used during the event, and the hospice aide did not have knowledge of the resident's specific care plan requirements for fall prevention.