Failure to Complete Fall Assessments and Ensure Proper Hoyer Lift Use
Penalty
Summary
The facility failed to complete necessary assessments, open a risk management report, create interventions for a fall, and use two staff when operating a Hoyer lift for two residents reviewed for falls. In the first case, a resident with dementia, dysphagia, frontal lobe deficit, hypertension, and a cardiac pacemaker experienced a fall. The resident was found on the floor next to her bed, was awake and alert, and had no obvious injury. Despite this incident, there was no fall assessment, no neurological checks, no change in condition assessment, no post-fall assessment, and no interventions documented for the fall. The care plan did not include any focus or intervention for the fall until a month later, after a second fall occurred. The resident's son confirmed that no interventions were implemented following the initial fall, and staff interviews revealed that standard procedures for post-fall assessment and intervention were not followed in this instance. In the second case, a resident with cerebral infarction, type II diabetes, vascular dementia, Parkinson's disease, and dysphagia was dependent on staff for all activities of daily living and required the use of a Hoyer lift with two-person assistance for transfers. The care plan and physician orders specified that two staff members were required for all Hoyer lift transfers. However, a CNA admitted to transferring the resident alone using the Hoyer lift because her coworker was busy with other residents. Other staff confirmed that the resident required two-person assistance for all transfers and that the proper procedure was not followed during this incident. Interviews with the Director of Nursing confirmed that the required assessments and interventions were not completed for the first resident's fall and that the second resident was transferred using the Hoyer lift by only one staff member, contrary to care plan and physician orders. These failures represent deficiencies in ensuring the area was free from accident hazards and that adequate supervision and assistance were provided to prevent accidents.