Failure to Develop and Implement Effective Fall Prevention and Transfer Interventions
Penalty
Summary
The facility failed to develop and implement adequate interventions to prevent falls and injuries for three residents with significant cognitive and physical impairments. For one resident with dementia, stroke, and right knee pain, the care plan did not address the resident's cognitive decline, impulsivity, or changes in bed mobility and transfer needs, despite multiple falls and documented confusion. Staff interviews revealed inconsistent awareness of care plan changes, and the care plan lacked specific interventions to address the resident's increasing tendency to self-transfer and not use the call light. Observations showed the resident wearing ill-fitting slippers and experiencing falls in various settings, including the dining room and their own room, with injuries such as head bumps and lacerations. The care plan was not revised to address the resident's mental decline, interrupted sleep, or the need for increased supervision during high-risk times. Another resident with severe cognitive impairment, a history of falls, and muscle weakness experienced multiple falls while ambulating unsupervised and wearing inappropriate footwear, such as open-toed sandals. The care plan instructed staff to provide direct supervision and use a walker for transfers, but the resident was observed walking independently and propelling themselves in a wheelchair without staff assistance. After falls, the only new intervention was to ask if the resident wanted to eat in a less stimulating environment, and there was no documentation of collaboration with the resident's representative to address unsafe footwear. Staff acknowledged that sandals were not appropriate but did not document efforts to replace them, and therapy notes regarding footwear assessment were unavailable. A third resident with muscle weakness and right foot drop required substantial assistance and the use of a sit-to-stand lift for transfers and bed mobility. However, staff interviews and observations revealed that transfers and bed mobility were frequently performed by a single staff member, contrary to the care plan's requirement for two-person assistance. Staff admitted to transferring the resident alone, sometimes physically lifting them without mechanical assistance, and not always following the care plan. The resident and a collateral contact confirmed that two-person assistance was rarely provided, and staff rationalized single-person transfers based on their own physical strength or convenience.