Failure to Implement Toileting-Related Fall Interventions and Complete Post-Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate fall interventions and conduct thorough post-fall investigations for a resident identified as high risk for falls. The resident had multiple serious medical diagnoses, including lung cancer, acute and chronic respiratory failure with hypoxia and hypercapnia, COPD, CHF, atrial fibrillation, diabetes, generalized anxiety, major depression, and chronic fatigue. The resident used a wheelchair, had moderately impaired cognition, required supervision/touching assistance for ADLs, partial to moderate assistance with toileting and transfers, and was always continent per the most recent MDS. Fall risk assessments on three separate dates identified the resident as high risk for falls. The care plan included one-person assist for transfers and toileting, assistance with toileting needs, evaluation of urination and incontinence patterns, and fall-risk interventions such as educating the resident to call for assistance, keeping items and call light within reach, monitoring mobility, and providing non-skid footwear. On one date, a fall occurrence evaluation documented that the resident was found on the floor by the bed, sitting on her buttocks, and reported attempting to use the bathroom when the fall occurred, with no injury noted. Interventions listed after this fall included education to call for assistance, keeping food/fluids within reach, and providing non-skid footwear, but did not include a toileting schedule or assistance to the bathroom, despite the fall being related to toileting. A post-fall risk evaluation noted the resident had previous falls, used assistive devices, and had a weak gait. On another date, a subsequent fall occurrence evaluation documented that staff found the resident scooting along the floor in the hall, with the resident stating she had been using the bathroom, became shaky, and sat on the floor to avoid injury. The bedside commode and walker were at the bedside, and a head-to-toe assessment showed no new injuries. The facility again initiated fall protocol with similar interventions (education, food/fluids within reach, non-skid footwear) but did not add a toileting schedule or specific assistance to the bathroom, and there was no documentation of what interventions were in place at the time of the fall, when the resident was last observed, or whether the call light was activated. Further observations showed the resident seated on the bedside with anti-embolism stockings on both lower extremities, with the stocking toes dangling and not securely in place, and no slip-resistant footwear applied. Another observation found the resident seated on a bedside commode without slip-resistant footwear. An LPN stated she was unaware the resident was up at the bedside without supervision and indicated the resident was supposed to be assisted by staff for transfers and not self-transfer. The DON confirmed that no interventions had been implemented to determine the resident’s bowel and bladder habits or a toileting schedule, and acknowledged that the resident’s falls were related to self-transferring to the toilet and bedside commode. The DON also verified that the fall investigation documentation for both falls lacked information on interventions in place at the time of the falls, when the resident was last observed, and whether the call light was activated, despite the facility’s fall policy requiring identification and adjustment of interventions based on resident-specific risks and causes.
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