Failure to Implement Fall Prevention Intervention Results in Resident Fall
Penalty
Summary
A resident with severe vascular dementia, type 2 diabetes, and generalized osteoarthritis, who was assessed as being at high risk for falls, did not receive adequate supervision and assistance to prevent accidents. The resident's care plan included the use of Dycem, a non-slip material, in the wheelchair to prevent sliding and falls. On the date of the incident, the resident slid out of the wheelchair and fell to the floor; it was confirmed that the Dycem was not in place at the time of the fall. The facility's policy requires that individualized care plans and interventions, such as the use of Dycem, be communicated to all appropriate staff and implemented to prevent avoidable accidents. The resident's CNA Kardex also documented the need for Dycem in the wheelchair. Interviews and record reviews revealed that the CNA responsible for the resident did not ensure the Dycem was in place at the beginning of the shift, as required. The CNA acknowledged that the intervention was supposed to be checked but was not, and both the CNA and the unit manager confirmed that the absence of Dycem led to the fall. The facility's investigation determined that the root cause of the fall was the missing Dycem in the wheelchair, which was an established intervention for this resident. The resident was found on the floor without injury, and it was noted that the correct wheelchair cushion was present, but the Dycem was not. The deficiency was identified through interviews, record reviews, and the facility's own investigation, which confirmed that the required fall prevention intervention was not implemented at the time of the incident.