Failure to Implement Fall Prevention Interventions Results in Resident Injury
Penalty
Summary
Staff failed to implement fall prevention interventions for a resident with multiple high-risk factors, including atrial fibrillation, dementia, major depressive disorder, Parkinson's disease, and a history of falls. The resident required substantial to maximal staff assistance for transfers and mobility, used a walker and wheelchair, and was assessed as a high fall risk. The care plan specified the use of a chair sensor alarm to notify staff when the resident attempted to get up unassisted, and staff were instructed to ensure the alarm was moved between seating surfaces and was functioning when in use. The care plan also required staff to ensure the resident wore appropriate footwear and that the environment was free of hazards. On the day of the incident, the resident was found on the floor in front of the bathroom, alert but holding her head and complaining of pain. She was wearing regular socks, with her shoes left by her recliner, and her call light was attached to the recliner, not within her reach. The chair sensor alarm, which was supposed to be in use, was found at the foot of the bed and was not active at the time of the fall. There were no environmental hazards identified in the room. The resident sustained a head hematoma and was later diagnosed with a fractured hip, requiring hospitalization and surgery. The facility's investigation could not determine the exact cause of the fall, as it was unwitnessed, but identified contributing factors including the resident ambulating without non-skid footwear and the absence of an active chair alarm. The failure to ensure the implementation of these fall prevention interventions, as outlined in the resident's care plan, directly led to the resident's fall and subsequent injuries.