Failure to Provide Required Assistance and Person-Centered Fall Prevention
Penalty
Summary
The facility failed to provide the required level of assistance for a resident with significant cognitive and physical impairments, resulting in an unwitnessed fall and a serious injury. The resident, who had diagnoses including diabetes, muscle weakness, lack of coordination, congestive heart failure, peripheral vascular disease, and severe cognitive impairment, was assessed as needing moderate assistance for bed mobility, transfers, ambulation, and maximum assistance for toileting hygiene. Multiple therapy and nursing assessments consistently documented the resident's need for one-person physical assistance with these activities of daily living (ADLs) and identified the resident as being at moderate risk for falls. Despite these documented needs, the resident's comprehensive care plan did not include person-centered interventions specifying the required assistance for bed mobility, transfers, ambulation, toileting, and hygiene. On the date of the incident, the resident attempted to use the toilet independently without staff assistance, resulting in an unwitnessed fall in the resident's room. The fall led to a right femoral neck fracture, which required surgical intervention. Interviews with facility staff, including CNAs, LVNs, therapy staff, and the DON, confirmed that the resident required moderate to maximum assistance and that no staff were present to provide the necessary help at the time of the fall. Further review of facility policies indicated that care and services should be provided to ensure residents' ADLs do not diminish and that a resident-centered fall prevention plan should be implemented for those at risk. However, the care plan for this resident lacked documentation of person-centered interventions to address the identified risks and required assistance levels. The absence of these interventions and the lack of staff presence at the time of the fall directly contributed to the resident's injury.