Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's bed was in the lowest position and that a fall mat was in place beside the bed, as required by the resident's care plan and facility policy. The resident, who had diagnoses including dementia, cognitive communication deficit, weakness, unsteadiness on feet, and chronic pain, was identified as a fall risk with specific interventions documented in her care plan, such as a bed alarm, floor mat, and bed in the lowest position at night. Despite these interventions, the resident's bed was left in a high position and the fall mat was not beside the bed at the time of the incident. The incident was discovered when the resident's roommate called for staff, who found the resident lying face down on the floor next to her bed. The resident reported that she had rolled out of bed and landed on her face. Staff and progress notes documented multiple injuries, including dark purple contusions to the face, neck, wrist, hand, and forearm, swelling to the eye, eyebrow, and forehead, and skin tears to the right forearm and left hand. Staff interviews confirmed that the bed was not in the lowest position and the fall mat was not in place, with one CNA stating she was overwhelmed and forgot to return the bed to the low position after care, and that the fall mat had been pushed under the bed. Further interviews with staff and the resident's family confirmed that the required fall prevention interventions were not in place at the time of the fall. The LPN on duty did not hear a bed alarm and confirmed the bed was in a high position with no fall mat beside it. The family was notified after the fall and provided photographic evidence of the resident's injuries. The facility's policy required safety interventions for residents at risk of falling, but these were not followed in this case, resulting in the resident sustaining significant injuries from the fall.