Failure to Implement Fall Prevention Interventions and Timely Post-Fall Assessment
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned interventions and did not complete a comprehensive fall evaluation in a timely manner for a resident identified as being at risk for falls. The resident, who had diagnoses including sepsis, obesity, and type 2 diabetes with diabetic neuropathy, required substantial to maximal assistance for transfers and personal care. Despite being cognitively intact and having no upper or lower extremity impairment, the resident's care plan included specific interventions such as education on proper hand placement during sit-to-stand transfers, encouragement to use assistive devices properly, and provision of rest periods. However, these interventions were not followed during a transfer using a sit-to-stand lift, resulting in the resident sliding out of the lift and being lowered to the floor by a CNA. Following the incident, the resident reported that the CNA was impatient and did not ensure her hands were correctly placed on the lift, nor was the safety belt properly secured. The resident expressed that she communicated her concerns during the transfer but was ignored, leading to her sliding out of the lift, hitting her knee, and experiencing pain and anxiety. Observations after the fall revealed a reddened area on her right knee and missing artificial fingernails, consistent with her account of the incident. The resident also stated that her vital signs were not checked, she was not asked about pain, and she did not receive prompt attention or medication for her pain and anxiety. A review of the medical record and facility documentation showed no evidence that vital signs were checked at the time of the fall, no comprehensive pain assessment was completed, and no physical assessment was documented in the progress notes. Additionally, the fall investigation lacked staff witness statements and a statement from the resident. The facility's policy required prompt medical attention, assessment for injuries, and documentation of pertinent data following a fall, but these procedures were not followed in this case.