Failure to Prevent Avoidable Fall Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure the safety of a resident with dementia and anxiety, who was identified as being at risk for falls due to confusion and behavioral symptoms. The resident, who was severely cognitively impaired and exhibited both physical and verbal aggression, began escalating in behavior, including tapping on the medication cart and attempting to throw the narcotic book. In response, a nurse placed a Dinamap device in front of the resident, which the resident then grabbed and shook. The nurse let go of the device, causing it to move, and the resident lost balance, fell backward, and struck his head on closed doors. As a result of the fall, the resident lost consciousness briefly and sustained a laceration to the head and a skin tear to the right hand, requiring transfer to the hospital for treatment, including staples and Steri-Strips. Facility documentation and staff interviews confirmed that the action of placing the Dinamap in front of the resident introduced a safety risk and directly contributed to the avoidable accident and resulting injuries.