Failure to Assess and Implement Fall Prevention Measures During Weighing Procedure
Penalty
Summary
A deficiency occurred when the facility failed to adequately assess and implement safety measures for a resident identified as at risk for falls, resulting in actual harm. The resident, who had chronic kidney disease, was dependent on renal dialysis, and had an acquired absence of the right leg below the knee, returned from a hospital stay with instructions indicating an increased risk for falls. Upon readmission, there was no documented evidence that the facility performed a comprehensive assessment of the resident’s care needs, including fall risk or the need to update the care plan, despite facility policy requiring such assessments upon readmission. On the day of the incident, staff transferred the resident from his personal wheelchair, which had leg rests, into a facility weight chair that lacked leg rests or other individualized safety features. The weighing procedure was not conducted using the ADA-compliant wheelchair platform scale as intended, which would have allowed the resident to remain in his own wheelchair with proper supports. During the transfer and weighing process, the resident leaned forward and fell from the weight chair, sustaining multiple abrasions and a cervical spine fracture. Staff interviews confirmed that safety devices were not transferred to the weight chair and that the facility did not routinely use individualized safety equipment during weighing procedures. Post-incident documentation and interviews revealed that the resident experienced significant pain and required further medical evaluation, which confirmed a cervical spine fracture. The facility’s failure to reassess the resident after a significant change in condition, ensure the use of appropriate assistive equipment, and supervise the weighing procedure according to safe practices and the intended use of the scale directly resulted in the resident’s fall and injury.