Failure to Prevent Accident Hazards and Integrate Person-Centered Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with severe cognitive impairment and a history of falls. The resident, diagnosed with Alzheimer's disease and assessed as severely cognitively impaired with a BIMS score of 3 out of 15, was admitted with multiple risk factors including confusion, impulsivity, and a recent history of recurrent falls. Despite the family's provision of detailed information regarding the resident's routines and preferences, such as sleeping in a recliner in street clothes and keeping a specific TV channel on, this information was not incorporated into the resident's baseline or comprehensive care plan, nor was it communicated to frontline staff through the Kardex or other official documentation. The facility's own fall prevention policy required individualized interventions based on assessment and family input, but the care plans lacked person-centered interventions and did not address the resident's behavior of deactivating her own alarm system. Staff relied on educating the resident as a fall prevention measure, despite documentation that the resident was only oriented to self and unable to reliably follow instructions due to severe cognitive impairment. The alarm system intended to alert staff to self-transfers was either not functioning or was turned off at the time of the resident's unwitnessed fall, and there was no documentation of interventions or monitoring related to the resident's known behavior of disabling the alarm. As a result, the resident experienced multiple falls, including an unwitnessed fall that resulted in a left hip fracture requiring surgical intervention. Interviews with staff revealed that key information about the resident's preferences and routines was not available in the care plan or Kardex, and staff were unaware of these preferences, leading to deviations from the resident's established routine. The facility's management acknowledged that person-centered information provided by the family was not integrated into the care planning process, and the care plan did not include goals or interventions to address the resident's behavior of disabling her alarm.