Failure to Implement and Communicate High Fall-Risk Care Plan During Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to implement an established comprehensive care plan for a resident identified as high risk for falls and dependent for toileting hygiene and bed mobility. The resident, an alert and oriented, predominantly Polish‑speaking older adult with multiple comorbidities including a history of falls and fractures, had a care plan and MDS/CAA documentation indicating high fall risk and a need for extensive assistance of at least one staff member for bed mobility and incontinence care. Care plan interventions included maintaining the bed in a low position, encouraging slow transfers and position changes, frequent toileting, and keeping commonly used items within reach. Despite this, on the date of the incident, an agency CNA provided incontinence/ADL care with the resident in a side‑lying position, using one hand to stabilize the resident and the other to clean her after a large bowel movement. The CNA reported that the resident reached toward the bedside table and then rolled out of the bed, and the CNA was unable to prevent the fall. Following the fall, the nurse assessed the resident, who complained of right shoulder pain and had a laceration above the right eye; the resident was sent to the ED and returned with a diagnosed right humerus fracture and a laceration treated with Steri‑strips. Interviews revealed that the agency CNA had not previously cared for the resident, did not receive any report or endorsement about the resident’s care needs, did not know the resident was a fall risk, and reported not receiving fall‑prevention training from the facility. Additional interviews with an LPN and an agency LPN showed they did not consider the resident to be a fall risk, were unaware of the resident’s high fall‑risk status, and one LPN stated the resident had never fallen out of bed and that she was never told the resident was high risk for falls. Staff also reported there were no side rails on the bed and no communication board in use, and the agency LPN stated she did not receive in‑service training from the facility and could not describe fall‑prevention measures for this resident. These findings demonstrate that the facility failed to implement and communicate the resident’s comprehensive fall‑risk care plan and required level of assistance during bed mobility and ADL care, resulting in a fall with significant injury.
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