Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident identified as high risk for falls. The resident, who had diagnoses including cerebral infarction, aphasia, altered mental status, and severe cognitive impairment, was assessed as a high fall risk based on the facility's fall risk assessment protocol. Despite this, the resident's care profile did not reflect fall precautions, and interventions such as 30-minute safety checks and floor mats were either not implemented or not documented as required by facility policy. Staff interviews revealed that the resident was observed attempting to get out of bed prior to the fall, with half of their body hanging off the bed, but this observation did not result in additional interventions or updates to the care plan. The resident was dependent for bed mobility and transfers, and staff had varying perceptions of the resident's ability to move or self-transfer. On the night of the incident, the resident was found on the floor with injuries including a swollen eye, hematoma, and a scratch, after reportedly attempting to get out of bed to retrieve belongings. The facility's documentation and communication regarding fall risk interventions were inconsistent, with some staff unaware of the resident's increased risk and others noting that required safety measures were not in place or not documented. The facility's fall risk intervention protocol required immediate implementation of prevention measures for residents with high fall risk scores, but the resident's care plan and care profile were not updated accordingly. The lack of documentation and failure to implement or communicate appropriate interventions contributed to the resident sustaining actual harm from a fall. The deficiency was substantiated by observations, record reviews, and staff and representative interviews, which highlighted lapses in supervision, care planning, and adherence to established safety protocols.