Failure to Prevent Accidents and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for two of three residents reviewed. One resident, with diagnoses including cerebral palsy, hemiplegia, and mild cognitive impairment, required total assistance for incontinence care and personal hygiene. During daily ADL care, a CNA attempted to turn the resident away from themselves to perform incontinence care, resulting in the resident rolling out of bed and sustaining a displaced intertrochanteric fracture of the right femur. Staff interviews revealed that facility training instructs staff to roll residents toward themselves or to seek assistance if a resident must be turned away, but this protocol was not followed in this instance. Another resident, with a history of epilepsy, breast cancer, and chronic pain syndrome, was identified as being at risk for falls and required supervision for bed mobility and transfers. The resident's care plan included interventions such as placing reminder signs in the room and removing trip hazards, but these interventions were not implemented. The resident experienced a fall while attempting to self-transfer from a wheelchair to a commode. During the survey, a folded-up sheet was observed on the floor in the resident's room, which staff acknowledged as a trip hazard, but it had not been addressed or documented in the care plan. Additionally, the required reminder signage was not present in the room. The facility's fall risk evaluation for the second resident was not completed accurately, as the assessment failed to account for the number of high-risk medications the resident was taking, which would have resulted in a higher fall risk score. Staff interviews confirmed that the fall risk evaluation was not properly completed, and there was a lack of clarity among staff regarding the process for addressing resident requests that may pose safety risks. These deficiencies demonstrate a failure to implement and monitor individualized interventions and assessments as outlined in the facility's own policies.