Failure to Implement Care-Planned Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement established fall-prevention interventions for a resident assessed as at risk for falls. The resident had intact cognition with a BIMS score of 15/15 and diagnoses including fracture with multiple trauma, CVA, muscle wasting and atrophy, Type 2 DM, CKD, history of TIA, and a history of fall with left hip fracture and repair. The care plan, revised on multiple dates, identified that the resident required supervision or touching assistance with transfers and walking, assistance of one staff member for transfers and ambulation to and from the bathroom using a wheeled walker and gait belt, and specific fall-prevention interventions. These interventions included not leaving the resident unattended in a wheelchair in the room, assisting with ambulation and transfers as needed, and having a sign in the room instructing use of the call light. Despite these care-planned interventions, observations on several dates showed the resident propelling herself in a wheelchair from the dining room to her room, entering and using the bathroom independently, and transferring herself from the wheelchair to a recliner without staff assistance. On one occasion, the resident was observed ambulating independently from the bathroom while pushing the wheelchair backwards with a stooped posture before sitting in a recliner. The resident had a documented unwitnessed fall in her room after self-ambulating to get a blanket without using the call light, stating she thought she could do it herself. A sign instructing staff not to leave the resident unattended in a wheelchair in the room was present, and staff interviewed acknowledged that the resident required one-person assistance with a walker and gait belt and that interventions included not leaving her unattended in the wheelchair in her room. The facility’s fall policy required that, based on assessment, interventions be implemented and placed on the care plan, but the observed practices did not align with the care-planned interventions for this resident.
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