Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, total dependence for activities of daily living, and a history of falls was not provided with the required safety interventions as outlined in her care plan. The resident, who had diagnoses including anoxic brain damage, convulsions, aphasia, and pseudobulbar affect, was care planned to have bolsters on her bed to minimize the risk of rolling out and for the bed to be kept at an appropriate height when unattended. On the day of the incident, the resident was returned to bed by a CNA who used a black wedge positioning device instead of the prescribed bolsters, which were found stored in front of the closet rather than on the bed. The incident was discovered when a nurse heard a loud thud and found the resident on the floor beside her bed, with a laceration to her face and a right leg injury. The bed was observed to be in a higher position, typically used for mechanical lift transfers, and there were no bolsters or wedge cushions on or around the bed at the time. The resident was subsequently diagnosed with a fractured right femur and required hospitalization and surgery. Interviews with staff revealed that the CNA was aware of the care plan requirements but did not use the bolsters, instead opting for a different device that was not part of the resident's care plan. Further review indicated that the CNA did not provide a clear reason for not using the prescribed bolsters, stating only that she used what was present on the bed that morning. The facility's documentation confirmed that all staff had access to the resident's care plan and Kardex, which specified the need for bolsters and bed positioning. The failure to implement these interventions as planned directly led to the resident's fall and subsequent injury.