Failure to Prevent Accident Hazards and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for two residents. For one resident with a history of repeated falls and diagnoses including Alzheimer's disease and osteoporosis, a floor mat intended to prevent injury was found with a wheelchair placed on top of it. Staff interviews confirmed that the resident placed the wheelchair on the mat himself, and that this practice was known to be hazardous. The care plan for this resident did not address the resident's refusal to keep the mat clear, and staff acknowledged that the mat should be free of objects or furniture to prevent injury and maintain its effectiveness. For another resident with chronic congestive heart failure, Alzheimer's disease, and dementia, who was identified as high risk for falls, there was no fall risk assessment completed after a fall incident. Progress notes indicated the resident was found on the floor mat after sliding off the bed, but no post-fall assessment was documented. Staff interviews revealed that fall risk assessments are required after such incidents to evaluate the resident's risk and determine necessary interventions, but this was not completed in this case. Facility policies reviewed indicated requirements for maintaining a hazard-free environment and for completing comprehensive, individualized care plans and fall risk assessments upon admission, quarterly, and after significant events such as falls. Manufacturer specifications for the floor mat also stated that heavy objects should not be left on the mat, as this could damage its protective function. The failure to follow these procedures and policies resulted in increased risk of accidents and injuries for the residents involved.