Failure to Implement Fall Precautions and Supervision Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and implement effective interventions to prevent a fall for a resident with significant risk factors. The resident had a history of dementia, muscle weakness, unsteady gait, and was dependent on staff for all activities of daily living except eating. The care plan included interventions such as keeping non-skid footwear on, ensuring the call light was within reach, placing a fall mat beside the bed, and requiring a mechanical lift with two staff for transfers. Despite these documented interventions, the resident was left unattended at the bedside without the fall mat in place while a staff member left the room to retrieve the mechanical lift. During the incident, one CNA left the resident alone in bed, with the bed in a low position and side rails up, but without the fall mat in place as required by the care plan. The protocol for transferring the resident called for one staff member to remain at the bedside while the other retrieved the lift, but this was not followed. Another CNA, who was in the room separated by a privacy curtain, discovered the resident on the floor with active bleeding from the head. The resident sustained a left knee fracture, a large scalp hematoma, and a right parietal subarachnoid hemorrhage as a result of the fall. Multiple staff interviews confirmed that the safest practice was not followed, as the resident was left unattended and fall precautions were not in place. Staff acknowledged that the fall mat was not positioned correctly and that the resident should not have been left alone, especially given her high risk for falls and cognitive impairment. The facility's fall policy required identification of at-risk residents and implementation of appropriate interventions, but these were not adhered to at the time of the incident.