Failure to Maintain Clutter-Free Environment and Adhere to Fall Prevention Care Plan
Penalty
Summary
A deficiency occurred when staff failed to adhere to a resident's care plan and maintain a safe, clutter-free environment, resulting in a fall and injury. The resident, who had diagnoses including dementia, muscle weakness, a history of falls, and macular degeneration, was identified as being at high risk for falls. Despite care plan interventions such as keeping the area clutter-free and monitoring for fatigue, staff did not report or address the resident's repeated behaviors of leaning forward and rocking in the wheelchair. Multiple staff members observed these behaviors but did not notify therapy or nursing leadership, and the behaviors were not incorporated into the resident's care interventions. On the day of the incident, a travel wheelchair belonging to the resident's roommate was left in the room, creating an obstruction. The resident, who required substantial assistance with transfers and verbal cues to navigate obstacles, was found to have fallen forward out of the wheelchair, striking their head on the brake handle of the unattended travel wheelchair. This resulted in a laceration to the left eyelid, requiring emergency department evaluation and sutures. The fall was unwitnessed, and the presence of the extra wheelchair in the room was confirmed by staff interviews and facility documentation. Facility policy required staff to identify and address environmental hazards and resident-specific risk factors for falls, including mobility and cognitive status. However, the interdisciplinary team was not informed of the resident's ongoing forward-leaning and rocking behaviors, and the environmental hazard posed by the improperly stored wheelchair was not addressed. The lack of communication and failure to follow established protocols contributed directly to the resident's fall and injury.