Failure to Implement Fall Prevention and Safe Transfer Protocols
Penalty
Summary
The facility failed to implement fall prevention interventions for two residents, resulting in deficiencies related to accident hazards and inadequate supervision. For one resident with orthopedic aftercare needs and a recent fracture, the care plan required fall mats to be placed on both sides of the bed while the resident was in bed. However, during observation, the fall mats were found against the wall and not in position as required, despite a physician order and care plan specifying their use. A registered nurse confirmed that the mats should have been in place while the resident was in bed. Another resident, who had diagnoses including acute respiratory failure and required a wheelchair for mobility, was dependent on staff for transfers and had a care plan specifying the use of a bed enabler, floor mat, and perimeter air mattress for fall prevention. The resident experienced a fall when a CNA attempted a Hoyer lift transfer alone, contrary to facility policy and the resident's care plan, which required two staff members for such transfers. The CNA reported that the resident became agitated while waiting for assistance, leading her to proceed alone, and the resident slipped out of the Hoyer lift pad and fell to the floor. The incident was witnessed and documented, and the resident later reported pain, prompting further medical evaluation. Additionally, repeated observations showed that the resident's bed was not kept in the lowest position as required by the care plan, and this was confirmed by a licensed nurse. Review of facility policies indicated that two staff members are required for mechanical lift transfers and that fall prevention interventions should be implemented based on assessment results. These failures affected two of three residents reviewed for accidents or falls.