Failure to Implement Fall Prevention Interventions Results in Resident Harm
Penalty
Summary
The facility failed to protect residents from neglect by not implementing required interventions to prevent falls for two residents. In the first case, a resident who required a bed alarm as a safety precaution was found on the floor with multiple injuries, including a laceration above the left eye and contusions to the face. Documentation revealed that the bed alarm was not activated at the time of the fall, despite being present on the bed. The nurse aide responsible for the resident did not check to ensure the alarm was functioning after placing the resident in bed, which was a direct violation of the resident's care plan and the facility's policy on fall prevention. In the second case, another resident assessed as dependent for bed mobility and requiring the assistance of two staff members was receiving care when she rolled out of bed and sustained a right distal femoral fracture. Staff statements indicated that only one nurse aide was present at the bedside while the other was in the bathroom gathering supplies, resulting in the resident being left without the required level of assistance. The care plan for this resident specifically required two staff for bed mobility, and this was not followed at the time of the incident. The facility's policies defined neglect as the failure to provide necessary goods and services to avoid physical harm, including the absence of reasonable accommodations for individual needs. In both incidents, the staff did not follow established care plans and safety interventions, leading to substantiated findings of neglect. There was no evidence in the report that the Director of Nursing or Nursing Home Administrator was notified immediately following the incidents, nor that all employees received in-service training after the substantiated neglect events.