Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned fall interventions for a resident with a history of falls, cognitive deficits, and diminished safety awareness. The resident, who had diagnoses including Alzheimer's disease, dementia, and a prior sacral fracture, was identified as high risk for falls and required specific interventions such as keeping the bed at transfer height, hourly purposeful rounding, and removal of wheelchair footrests except during transport. Despite these interventions being documented in the care plan, they were not followed on the day of the incident. On the day of the fall, the resident was found seated in her wheelchair with foot pedals attached and a blanket wrapped around her, placed there by overnight staff. Staff interviews confirmed that the foot pedals should have been removed when the resident was not being transported, as she was known to attempt to stand up independently and was not directable due to her cognitive condition. The resident was left unsupervised in a common area, and staff were occupied in other rooms when a yell and crash were heard. The resident was found on the floor against a plastic barrier, exhibiting signs of a right femoral fracture. Documentation and staff interviews indicated that the presence of the foot pedals may have contributed to the resident's fall. The care plan was not followed, as the foot pedals were not removed and adequate supervision was not provided. As a result, the resident sustained a hip fracture that required surgical intervention.