Failure to Provide Required Two-Person Assist and Post-Fall Nursing Assessment
Penalty
Summary
Surveyors identified a deficiency in accident prevention and supervision related to one resident with significant cognitive and functional impairments. The resident had diagnoses including epilepsy, muscle weakness, gait and mobility abnormalities, and Alzheimer's disease, and the MDS documented severely impaired cognitive skills for daily decisions and total dependence on staff for ADLs, requiring assistance of two or more helpers. Therapy evaluations and care plans showed impaired bed mobility, functional transfers, ambulation, safety awareness, impulsive behavior, attempts to get up unassisted, poor safety awareness, and inability to control body positioning, with bathing documented as requiring total dependence without attempts to initiate. A fall risk assessment scored the resident as high risk for falls. Despite these documented needs, the facility failed to ensure the resident was assisted with at least a two-person assist during mobility and transfers as indicated by the MDS. In addition, after the resident slipped on the floor while being given a shower, the resident was not evaluated and assessed by a licensed nurse as required by the facility’s policies and procedures titled "Falls - Clinical Protocol" and "Falls and Fall Risk, Managing." This failure to follow the resident’s assessed assistance needs and the facility’s fall assessment protocols resulted in the resident’s fall and had the potential to place the resident at risk for recurrent falls.
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