Failure to Follow Fall Prevention Interventions Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow established fall prevention interventions for a resident with significant risk factors. The resident, who had an above right knee amputation, dementia, and hemiplegia, was assessed as cognitively intact but required maximum assistance for toileting and transfers. The care plan specifically indicated that the resident should not be left alone in the bathroom due to a high risk for falls. Despite this, a CNA placed the resident in the bathroom and left her unattended while assisting another resident. The resident attempted to stand up alone to retrieve a brief, lost her footing, and fell, resulting in a fractured right hip that required surgical intervention. The CNA later stated she was unaware of the care plan intervention not to leave the resident alone in the bathroom. Facility leadership confirmed that the care plan was not followed, which contributed to the resident's fall and injury.