Failure to Implement Adequate Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to follow its fall prevention policy and did not ensure a safe environment for a resident identified as a high fall risk. The resident, who had a history of cerebrovascular disease, delirium, difficulty walking, and lack of coordination, was assessed as a high fall risk upon admission, with a fall risk score of 23. Despite this, the resident's care plan only included minimal interventions such as keeping the room free of clutter and rounding every two hours, which were not adequate for her risk level. Staff interviews revealed that high fall risk interventions, such as floor mats and increased supervision, were not consistently implemented. On one occasion, the resident fell in the dining room while attempting to get up from her wheelchair without assistance. At the time, only one CNA was present in the dining room, who was occupied cutting up another resident's food. The CNA was unable to intervene in time, and the resident was found on the floor with mild swelling to her face. The DON acknowledged that another staff member should have been monitoring the resident when the assigned CNA was assisting someone else. The resident was later diagnosed with an acute subdural hematoma and right eye hematoma following the fall. Additionally, the resident experienced a seizure while in her wheelchair in the cafeteria, during which she slumped over but did not fall. Staff noted that seizure precautions, such as bed bolsters or floor mats, were not in place. The facility's failure to implement and document appropriate fall prevention interventions for a high-risk resident, as required by their policy, resulted in the resident sustaining significant injuries.