Failure to Prevent Accidents and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision or implement fall prevention interventions for three residents reviewed for falls. Staff did not consistently follow policy and procedures for turning and repositioning dependent residents, reporting falls, or ensuring that staff were aware of and implemented individualized fall prevention interventions. Equipment intended to prevent falls, such as alarms and assistive devices, was not always in place or functioning properly. One resident with significant medical conditions, including congestive heart failure and chronic kidney disease, was assessed as high risk for falls and dependent on staff for repositioning. During care, staff failed to use an assistive device or a two-person assist as required, resulting in the resident falling from bed and sustaining an acute femoral neck fracture with significant pain. Documentation and staff accounts of the incident were inconsistent, and the care plan was not updated to reflect necessary interventions. Staff were also unclear about the resident's fall prevention measures, and required equipment was not observed in use during the survey. Other residents with histories of falls and impaired mobility were also not provided with appropriate interventions. One resident, dependent on staff for transfers, experienced multiple falls and was observed being transferred unsafely by a single staff member without proper equipment, despite care plan requirements. Another resident, also at high risk for falls and with severe cognitive impairment, was left without accessible call light assistance and was not provided with required transfer devices or functioning alarms. Staff were observed not responding promptly to requests for assistance, and fall prevention interventions outlined in care plans and facility policy were not consistently implemented.