Failure to Follow Care Plan for Fall Prevention Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents, resulting in actual harm to a resident who experienced a fall with a facial injury requiring sutures. The resident had diagnoses including Parkinson's disease, weakness, and dementia, and was identified as being at risk for falls. The resident's care plan specified that she should be seated in a BRODA chair in a reclined position with left lateral support at all times except during meals, to increase comfort and reduce the risk of falls. However, on the day of the incident, the resident was found on the floor in front of her BRODA chair, which was in the upright position, after calling for help. She sustained a 5-centimeter laceration below her right eye, which required 15 sutures at the hospital. Review of staff interviews and facility documentation revealed that a physical therapy assistant, who was a PRN staff member, returned the resident to the television area in her wheelchair in the upright position after a treatment session, failing to follow the care plan intervention requiring the chair to be reclined. Nursing staff confirmed that the resident's wheelchair was not reclined at the time of the fall, and that the reclined position was intended to make it more difficult for the resident to get up unassisted, thereby preventing falls. The failure to follow the care plan intervention directly resulted in the resident's fall and subsequent injury.