Failure to Prevent Falls and Ensure Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent falls for three residents. One resident with a history of multiple fractures, severe cognitive impairment, and high fall risk was found on the floor in her room after a fall. Her care plan required the use of bed and chair alarms, but at the time of the incident, the alarm was not attached, and staff were unaware of the correct alarm type to use. The resident's environment also had poor lighting during the fall, and her medical record lacked a documented fall risk assessment. Another resident, who was dependent on staff for mobility and transfers and had a history of falls, slipped out of her wheelchair while being loaded into a facility van. Staff failed to ensure the use of foot pedals on the wheelchair, which contributed to the resident sliding forward and falling. The incident resulted in skin tears, and there was no documentation of a completed investigation or root cause analysis for the fall, despite facility policy requiring such actions after every fall. A third resident, with osteoarthritis and a moderate fall risk, experienced a fall when he was lowered to the floor by staff and subsequently dropped himself to the floor again. His care plan did not include new interventions after the fall, and there was no documentation of an investigation or root cause analysis. Staff interviews confirmed that the resident had a history of not using his call light and getting up on his own, which contributed to his fall risk. The facility's fall prevention policy required assessment and care plan review after each fall, which was not consistently followed.