Failure to Properly Implement Fall Interventions Resulting in Resident Injury
Penalty
Summary
The facility failed to properly implement fall interventions for a resident with advanced dementia, poor balance, and a history of impulsiveness. The resident, who was at high risk for falls and required substantial assistance for transfers, attempted to stand up unassisted from her wheelchair and fell. At the time of the fall, the resident's chair alarm did not sound because the pull-tab alarm string was too long and remained attached to her shirt and the magnetic tab, preventing activation. Staff were required to ensure the alarm was properly placed and functioning each shift, but this was not done effectively, resulting in the alarm failing to alert staff as the resident attempted to stand. Following the fall, the resident complained of pain and was found to have sustained a mildly impacted non-displaced left femoral neck fracture. The resident's care plan included multiple fall interventions, such as a low bed, fall mats, a scoop mattress, anti-rollbacks on her wheelchair, and a pull-tab alarm, all intended to address her lack of safety awareness and high fall risk. Despite these interventions being documented, the improper setup of the alarm directly contributed to the resident's fall and subsequent injury.