Failure to Follow Care Plan for Lift Recliner and Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow care-planned safety interventions for a resident with a history of falls and use of an electric lift recliner, resulting in an avoidable accident with actual harm. The resident had dementia, depression, overactive bladder, and osteoporosis, and the MDS showed intact cognition but a need for substantial to maximal assistance with transfers and toileting. The care plan, revised in December, identified risk for injury related to falls and specifically to electric recliner use, with interventions including keeping the electric lift recliner unplugged so it functioned only as a stationary chair, use of appropriate footwear, grip strips in the room, and signage. The Kardex also instructed staff, per therapy, to keep the recliner unplugged to promote safety. Despite these documented interventions, the resident experienced multiple falls associated with the recliner. An incident report from late May documented the resident being found face down on the floor in front of the recliner, which was in the highest position, suggesting an attempted self-transfer; the post-fall investigation concluded the resident appeared to have attempted to self-transfer and directed that the recliner remain unplugged. A subsequent incident in mid-December again found the resident face down on the floor with pooling blood, a large frontal hematoma, a skin tear, and complaints of hip, elbow, and neck pain, with the recliner again in the highest position. The post-fall investigation and ED provider note both indicated the resident attempted to get out of the lift chair after it had been plugged in, despite the care plan stating the chair was to remain unplugged. Staff interviews confirmed that the care plan intervention to keep the recliner unplugged was not consistently followed. Nursing staff and NAs acknowledged awareness that the recliner was not supposed to be plugged in due to prior falls but reported they did not routinely check whether it was plugged in, sometimes assuming no one would have plugged it in. Staff and a family member stated that both staff and family had plugged in the chair at times, and the family member reported the resident would not have been able to plug it in herself. Observations also showed the resident seated in a wheelchair with regular nylon socks rather than anti-slip footwear, even though appropriate footwear was a listed intervention in the care plan. The facility’s own policy stated that the care plan is to guide daily care and that the Kardex is comprised of care plan interventions, and that health care personnel are responsible for following the care plan, yet the interventions related to the recliner and footwear were not implemented as written.
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