Failure to Maintain Accident-Free Environment and Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision to prevent accidents for one resident identified as high risk for falls. The resident, who had multiple diagnoses including muscle wasting, vascular dementia, hemiplegia, and moderate to severe cognitive impairment, experienced four unwitnessed falls during their stay. These falls resulted in significant injuries, including a mandibular fracture and a rib fracture. The resident's care plan included specific interventions such as keeping a urinal and reacher at bedside, ensuring the call light was within reach, and providing assistance with activities of daily living and toileting. Despite these care-planned interventions, observations and interviews revealed that the urinal and reacher were not present at the resident's bedside as required. The call light was also observed on the floor and not always within reach. Staff interviews confirmed that these interventions should have been in place according to the care plan, but they were not consistently implemented. The facility's own policies, including the Falling Star Program for high fall risk residents, were not fully adhered to, as evidenced by the lack of required fall prevention equipment in the resident's room. Documentation showed that the resident's falls were frequently related to attempts to self-transfer, particularly to use the bathroom, and that interventions such as a bedside urinal were specifically intended to address this risk. However, the absence of these interventions contributed to repeated falls and injuries. The facility's monitoring and communication systems did not ensure that all staff were aware of and consistently implemented the required fall prevention measures for this high-risk resident.