Failure to Prevent Accidents and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for four residents, as evidenced by incomplete fall investigations, failure to perform post-fall neurological assessments, improper transfer techniques after a fall, and lack of implementation of fall prevention interventions. One resident with multiple medical diagnoses, including a history of falls and severe cognitive impairment, was found on the floor and was manually lifted back to bed by staff instead of using a mechanical lift as required by the resident's care plan and facility policy. Neurological assessments were not completed per policy after the unwitnessed fall, and the fall investigation did not include interviews with all involved staff or determination of a root cause. The resident subsequently developed swelling and pain in the right leg, which was later diagnosed as an acute, displaced femur fracture. Another resident, identified as a fall risk and cognitively intact, had a care plan intervention for a non-slip mat in the wheelchair, but repeated observations showed the mat was either missing or improperly placed. This resident had a history of multiple falls and was observed with visible bruising. The Director of Nursing confirmed the absence or improper placement of the non-slip mat during interviews and observations. Two additional residents, both at risk for falls and not cognitively intact, had care plans specifying interventions such as body pillows, bed alarms, overlay bolsters, fall mats, and accessible call lights. Observations revealed that these interventions were not in place as required: body pillows and bed alarms were missing, overlay bolsters were not present, and call lights were out of reach or on the floor. Staff interviews and direct observation confirmed these deficiencies, and the facility's own policies required individualized fall prevention interventions based on resident risk assessments.