Failure to Prevent Accidents and Implement Fall Interventions
Penalty
Summary
Three residents were not adequately protected from accident hazards, and the facility failed to provide sufficient supervision and interventions to prevent accidents. One resident with vascular dementia, anemia, and depression, who was assessed as being at risk for falls and required extensive assistance with activities of daily living, was observed multiple times without required fall interventions in place. Specifically, the resident's bed was not maintained in the lowest position, and a fall mat was not present at the bedside, despite these being recommended and documented interventions in the care plan following a previous unwitnessed fall. Staff interviews confirmed a lack of awareness and implementation of these interventions. Another resident with chronic atrial fibrillation and on blood thinning medication experienced multiple skin injuries, including skin tears and bruising, during care activities such as repositioning and transfers. There was no documentation of investigations into the causes of these injuries or implementation of new interventions to prevent further incidents. Interviews with nursing staff and review of records revealed that no root cause analysis or preventative measures were documented or put in place following these events. A third resident with dementia, weakness, and a history of repeated falls sustained an unwitnessed fall resulting in a large bruise to the forehead and face. Although a root cause analysis recommended therapy evaluations and adjustments to the toileting schedule, the care plan was not updated to reflect these interventions, and no therapy evaluation was conducted after the fall. Staff interviews confirmed that therapy services were not initiated as recommended, and the care plan lacked documentation of revisions or implementation dates for new interventions.