Failure to Remove Environmental Hazard for High-Risk Fall Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a resident with a known history of frequent falls and severe cognitive impairment. The resident was admitted with diagnoses including a displaced left humerus fracture, severe dementia with anxiety, and muscle weakness, and was assessed as a high fall risk with a Morse Fall Scale score of 50. MDS assessments documented severe cognitive impairment (BIMS 00/15 and later unable to complete), daily wandering, delusional behaviors, inattention, disorganized thinking, and both short- and long-term memory loss. The resident was described as active, ambulatory, and impulsive, with a pattern of attempting to stand or ambulate without assistance and requiring consistent redirection. Between late August and mid-December, the resident experienced ten documented falls, three of which resulted in major injuries, including a nasal fracture, a subdural hemorrhage with a right clavicle fracture, and later a right femur fracture. Progress notes described multiple unwitnessed and witnessed falls in various locations, including another resident’s room, during ambulation to the shower room, behind the nurse’s station, in front of the wheelchair in the dining room, at the nurse’s station, and in the hallway. Despite this pattern of falls and injuries, the fall care plan interventions remained limited to measures such as ensuring proper pants length, using nonskid strips, offering redirecting activities, removing slippers from the room, placing a resident identifier outside the room, and assisting or redirecting the resident when seen walking without assistance. On the date of the cited incident, staff left a large grey rolling trash receptacle in the hallway near the exit door by the resident’s room, contrary to staff training that the trash can must be kept in the shower room and not left in hallways except when being emptied into the dumpster. The resident, known to be impulsive and ambulatory, exited the room, attempted to use the rolling trash can for support, and fell when it rolled away, striking the rail and holding the right upper thigh, with a subsequent diagnosis of a right femur fracture. The room’s location near an outside exit door and far from the nurse’s station, combined with the resident’s established fall history and behaviors, and the presence of the rolling trash can in the hallway, constituted the facility’s failure to identify and remove an environmental hazard for a high-risk resident.
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