Failure to Maintain Hazard-Free Environment Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident's environment was not kept free of hazards, resulting in a fall. The incident involved a certified nursing assistant (CNA) who was preparing a resident in her room. The CNA encountered cords from an air mattress that were lying on the floor in front of the resident's wheelchair. While attempting to move the wheelchair over the cord, the CNA lifted the back of the wheelchair, causing the resident to fall forward out of the chair and hit her head on a mechanical lift. The resident sustained a bleeding injury to the right side of her head, which required cleansing and monitoring. The facility's fall prevention policy requires that resident environments be kept free of clutter and hazards, and that appropriate interventions be implemented based on individual risk assessments. In this case, the CNA did not remove the cord from the resident's path before attempting to move the wheelchair, and lifted the wheelchair in a manner that led to the resident's fall. The Director of Nursing confirmed that the CNA should have moved the cord and not lifted the wheelchair, indicating a failure to follow established safety protocols.