Failure to Ensure Safe Ambulation and Adherence to Care Plan Leads to Resident Fall With Facial Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff were competent in transferring and walking a resident who required transfer assistance, resulting in a fall with injury. The resident had diagnoses including respiratory failure, atrial fibrillation, osteoporosis, variants of Turner’s syndrome, and disorientation. On admission assessment, the resident had no documented cognitive or communication issues, used a front-wheeled walker (FWW), and required only supervision or partial assistance for transfers, ambulation, and toileting. The resident’s care plan directed staff to follow PT/OT for mobility, provide standby assistance for toileting and transfers with a FWW, and to have the resident ambulate to the bathroom with the FWW while staff remained present to provide encouragement. The care plan also noted mild loss of balance with the ability to recover independently and documented that the resident ambulated more safely with the FWW. On the day of the incident, the resident requested to walk as part of a walking program. According to the facility’s incident report and nursing progress notes, the resident was walking without the walker when she fell forward and struck her face, resulting in visible bruising, a hematoma to the right side of the head, and a nosebleed. The resident was transported to the ED, where she was diagnosed with a closed facial bone fracture and a brain bleed, and remained overnight before returning to the facility. The resident later reported that the nursing assistant had applied a gait belt but did not recall using the walker during the walk, and stated that the assistant was not holding the gait belt when they were walking. The resident described turning a corner and suddenly falling forward, characterizing the event as very traumatic. In a subsequent interview, the per diem nursing assistant reported that she had been told by other staff to let the resident do what she wanted and to stand by and watch. She stated that she found the resident in the bathroom without a walker or gait belt, assisted with toileting, and then allowed the resident to walk from the bathroom to the wheelchair without assistive devices. When the resident requested to walk in the hallway, the assistant offered the FWW with a wheelchair to follow, but the resident declined. The assistant stated she applied a gait belt, but when she attempted to hold it, the resident refused, insisting on walking independently. The assistant then followed behind as the resident walked from her room to the therapy entrance, where the resident mis-stepped at a dip in the floor and fell forward. The nurse manager, involved in the fall review, identified the root cause as the resident’s refusal to use the FWW combined with the assistant allowing the resident to ambulate without the prescribed assistive devices, contrary to the care plan and facility policies requiring use and proper handling of gait belts and assistive devices when indicated.
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