Failure to Prevent Recurrent Falls and Implement Person-Centered Interventions
Penalty
Summary
The facility failed to implement immediate interventions to prevent the recurrence of a fall incident involving a resident who sustained two brain bleeds and a femur fracture after falling from a full body mechanical lift. Upon the resident's return from the hospital following the fall, no new interventions were put in place to prevent a similar event, and there was no evidence of staff education or care plan revision until several days later. Multiple nursing assistants expressed concerns about the appropriateness of the sling size used during the transfer, with some stating the large sling was too big for the resident, but these concerns were not promptly addressed or communicated to management. The facility's policy lacked specific guidance on proper sling placement, and staff interviews revealed inconsistent understanding and application of sling sizing and positioning, which contributed to the incident. Additionally, the facility failed to implement person-centered fall interventions and complete a fall analysis for another resident who experienced multiple falls and sustained fractures. Incident reports and progress notes for this resident lacked evidence of a root cause analysis by the interdisciplinary team and did not document the implementation of new interventions to prevent future falls. Staff interviews indicated that while some immediate actions, such as increased monitoring, were taken, there was no systematic approach to updating care plans or communicating new interventions to all staff members. The lack of follow-up and individualized interventions after each fall event resulted in continued risk and actual harm to the resident. Both cases demonstrate that the facility did not ensure areas were free from accident hazards and did not provide adequate supervision or individualized interventions to prevent accidents. The failure to promptly assess, analyze, and address the causes of falls, as well as to communicate and implement appropriate changes in care, led to significant injuries for the residents involved. The documentation and staff responses indicate a lack of timely and effective action to mitigate fall risks and prevent recurrence.
Removal Plan
- Audit R4's lift equipment to ensure the sling is the appropriate size and in good condition
- DON observe a transfer with the staff and R4 to verify the resident is positioned safely and securely in the sling
- Revise R4's care plan and direct staff to remove the lift sheet immediately following each transfer
- Conduct a lift assessment for R4 to ensure type of lift and sling remain appropriate
- Educate all staff on concerns regarding transfers and R4's intervention
- Re-educate all staff per manufacturer's guidelines regarding proper sling application, loop selection, lift safety, and escalation procedures if concerns arise