Failure to Prevent Accident Hazards and Update Care Plan After Grievance
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident was free from accident hazards, resulting in an unwitnessed fall and subsequent injury. The resident, who was nonverbal, bedbound, and dependent on staff for all mobility and hygiene needs, had a history of traumatic brain injury, anoxic brain damage, and was on multiple medications including anticoagulants. Despite a family member's grievance about the resident being positioned near the edge of the bed and the behavior of dangling legs off the bed, the facility did not adequately investigate the concern or implement additional interventions to address the identified risk. The facility's documentation showed that the grievance was received and an in-service on proper positioning was conducted for staff, but there was no evidence of a thorough investigation or individualized interventions for the resident. The fall risk assessment for the resident was found to be inaccurate, as it did not account for all relevant medication classes, resulting in an incorrect fall risk score. Staff interviews confirmed that the resident frequently dangled his legs over the bed and slid down on the mattress, but this behavior was not documented in the medical record or addressed in the care plan prior to the fall. The care plan for the resident included general fall prevention measures but was not updated to reflect the specific risk of the resident's behavior of hanging his legs over the bed, even after the family member's grievance. The lack of accurate assessment, failure to update the care plan, and insufficient investigation of the grievance led to the resident experiencing an unwitnessed fall, sustaining a subdural hematoma, and requiring hospitalization.