Failure to Verify Agency Staff Competency and Provide Fall Prevention Training
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received care from staff with documented competency and training, particularly in fall prevention and resident-specific safety needs. An agency CNA was assigned to provide ADL care to an alert and oriented, predominantly Polish‑speaking resident with multiple diagnoses including type II diabetes, right humerus fracture history, COPD, atrial fibrillation, hypertension, anxiety disorder, and a history of falls. During incontinence care, the CNA positioned the resident on her side with one hand on the resident’s rib/shoulder area and the other hand cleaning a large bowel movement. The resident then reached toward the bedside table or an item on it, rolled out of the bed, and fell to the floor. The CNA reported there were no bed rails, that she did not understand the resident due to the language barrier, that it was her first time caring for the resident, and that no one had given her any information about the resident’s care needs or fall risk status. Following the fall, the resident complained of right shoulder pain and had a laceration above the right eye, was sent to the ED, and returned with a diagnosed right humerus fracture and a laceration treated with Steri‑strips. Record review showed that the facility’s orientation documentation for the agency CNA consisted of a form listing over two dozen training topics, including fall prevention and safety protocols, all marked only with a single continuous vertical strike‑through line and the CNA’s signature, without instructor initials, dates of completion, or evidence of observed competency by facility leadership. The CNA stated she did not recall receiving fall prevention training. An agency LPN caring for the same resident reported receiving no in‑service training from the facility, only from the agency, and incorrectly stated that the resident was not a fall risk despite being aware of a prior fall. When the surveyor requested a fall prevention policy, the administrator provided only a Fall Occurrence policy that addressed assessment and interventions after falls and confirmed there was no separate fall prevention policy. Review of the facility’s education modules showed staff were trained only on the fall occurrence policy, not on a proactive fall prevention framework. As a result, the agency CNA was assigned to a high‑risk resident without verified competency in the facility’s safety standards or resident‑specific fall prevention needs.
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