Failure to Implement Fall Prevention Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was implemented for a resident with dementia and osteoporosis, resulting in actual harm. The resident's care plan included specific fall prevention interventions such as a tab alarm at all times in bed and chair, bilateral floor mattresses/alarming floor mats, and a low bed. However, on the day of the incident, these interventions were not properly implemented. The bed was not in the low position, and the fall mats were not placed on the floor as required by the care plan. Clinical documentation and staff witness statements revealed that the certified nurse assistant (CNA) assigned to the resident did not fully follow the care plan. Although the CNA reported placing the bed in the lowest position and setting up alarms and mats, a subsequent statement admitted to failing to put down the second fall mat. Other staff who responded to the incident found the bed elevated, fall mattresses propped against the wall, and alarms not connected. This failure to follow the care plan led to the resident rolling out of bed, sustaining a 4-5 cm laceration to the forehead and a mildly displaced fracture of the proximal left femoral metaphysis (hip fracture). The incident was unwitnessed and occurred after the CNA had left the room. The resident required emergency medical attention, including repair of the facial laceration and hospital admission for orthopedic evaluation. The facility's investigation confirmed that the care plan was not followed, which directly resulted in the resident's injuries.