Failure to Implement Fall Prevention Interventions and Address Equipment Hazards
Penalty
Summary
The facility failed to implement resident-centered interventions to prevent falls for one resident, resulting in the resident falling from a wheelchair. The facility's fall policy requires individualized assessment and intervention, including the use of assistive devices and prompt repair or removal of malfunctioning equipment. Despite this, the resident's care plan did not include specific interventions to address the risk of falling from the wheelchair, and the intervention to tuck the lift sling straps under the resident was not transcribed to the care plan after the incident. The resident had multiple diagnoses, including fractures, diabetes with skin ulcer, and muscle wasting, and was dependent on a total body mechanical lift for transfers. The resident was cognitively intact and reported that the seatbelt on the power wheelchair was broken and could not be fastened. Staff were aware of the broken seatbelt, but maintenance was not notified, and the seatbelt was not repaired. The resident stated that the seatbelt was functional upon admission and that it was always worn when in the wheelchair. On the day of the incident, the resident was outside waiting for transportation to dialysis when the straps of the lift sling became tangled in the wheelchair's front wheel. While attempting to remove the straps, the resident slipped forward and fell from the wheelchair. The incident was reported to staff, and the resident was assessed and returned to the wheelchair. The lack of a functioning seatbelt and the absence of updated care plan interventions contributed to the fall.