Failure to Prevent Fall Due to Inadequate Care Planning and Faulty Equipment
Penalty
Summary
The facility failed to develop and implement a person-centered plan of care for fall prevention and did not ensure that a resident's bed was in proper working order. The resident in question had a recent below-the-knee amputation, was identified as high risk for falls, and required assistance with transfers. Despite these known risks, the care plan interventions were not adequately tailored to the resident's needs, and the environment was not maintained to prevent accidents. The resident attempted to self-transfer from bed to wheelchair due to an urgent need to use the bathroom. During this attempt, the bed rolled away because its locking mechanism was malfunctioning, causing the resident to fall. The fall resulted in the reopening of the surgical incision at the amputation site, leading to significant bleeding and requiring urgent hospital treatment and surgical revision. The resident reported that after the fall, he used his call light for assistance, but no staff responded in a timely manner, prompting him to crawl into the hallway to seek help. Interviews with maintenance and administrative staff confirmed that the bed's locking mechanism was not functioning and that the bed was replaced only after the incident. There was uncertainty among staff regarding when the issue was first reported and when corrective action was taken. The facility's fall prevention protocol required comprehensive risk assessments and individualized care plans, but these measures were not effectively implemented for this resident, contributing to the accident and subsequent injury.