Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
The facility failed to implement necessary fall prevention interventions for a resident identified as high risk for falls, resulting in a significant injury. The resident had multiple diagnoses including osteoarthritis, heart disease, lumbar disc displacement, anxiety, vertigo, repeated falls, glaucoma, type II diabetes, difficulty in walking, and psychotic disturbance with hallucinations. The resident was prescribed several medications known to increase fall risk, such as Haldol, Dilaudid, and Fentanyl. Despite being assessed as high risk for falls and having a recent history of falls, the resident was found alone in their room after a fall, with no fall mats in place and the bed not in the lowest position. The nightstand was positioned between the wall and the bed, and the resident was found partially under the bed, which was covered in blood along with the nightstand. Staff interviews confirmed that the fall prevention interventions, specifically the use of fall mats and maintaining the bed in the lowest position, were not in place at the time of the incident. The resident sustained an acute nasal fracture and a laceration requiring five sutures as a result of the fall. Observations after the incident further confirmed that the bed was not kept in the lowest position, and the Director of Nursing verified that if the bed had been lowered, the resident would not have been able to get under the bed. The lack of these interventions directly contributed to the resident's fall and subsequent injuries.