Failure to Implement Fall Prevention Interventions and Proper Use of Equipment
Penalty
Summary
The facility failed to follow established interventions and policies to prevent falls and ensure the safe use of equipment for two residents identified as high risk for falls. In the first case, a male resident with multiple diagnoses including bilateral osteoarthritis, dementia, gait abnormalities, and a history of repeated falls required extensive assistance for mobility and transfers. During a transfer from wheelchair to toilet, the certified nursing assistant (CNA) did not use the gait belt as required, instead placing it around her own waist rather than the resident's. This improper use of equipment led to the resident losing balance and sliding to the floor, resulting in pain and a subsequent injury. Staff interviews confirmed that the gait belt was not used according to facility policy, and the CNA admitted to not applying the belt to the resident as trained. In the second case, a female resident with dementia, gait abnormalities, and a history of falls was care planned to use a walker and receive assistance with ambulation. Despite this, she experienced an unwitnessed fall while sitting in a chair, which resulted in a left arm fracture. Interviews with staff and the resident's family revealed that the walker, although present in her room, was not being used, and staff were not consistently assisting or cueing her to use it. The resident was known to have an unsteady gait, poor safety awareness, and cognitive impairment, yet was observed to get up unassisted and walk without the prescribed walker. Staff were unaware of the walker being part of her care plan, and the assistant director of nursing confirmed the resident did not have a walker at the time of the fall. Both incidents demonstrate a failure to implement and follow individualized fall prevention interventions as outlined in the residents' care plans and facility policy. The lack of proper supervision, failure to use assistive devices as required, and inadequate staff adherence to transfer protocols directly contributed to the residents' falls and resulting injuries. These deficiencies were identified through observations, interviews, and record reviews conducted by surveyors.