Failure to Follow Orthotic and Fall-Prevention Precautions During Therapy Sessions
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient safeguards and supervision to protect residents from neglect, specifically by not ensuring that rehabilitation staff were aware of and implemented care plan interventions and physician orders related to fall prevention and orthotic use. For one resident with a history of hip replacement and right lower extremity weakness, the orthopedic physician ordered a hinged knee brace locked in extension for all weight-bearing activity, and an ARNP entered an order for non-weight bearing to the right lower extremity with the hinged brace locked in extension when weight bearing. The resident’s passport tip sheet, dated prior to the fall, included instructions for the brace to be locked in extension and specified no walking backwards or pivoting on the right leg. However, the OT and PT precaution sheets did not include the brace instructions until nine days after the fall, and the treating COTA reported that the leg brace was not on the daily notes or schedule and was not on the resident at the time of the incident. On the day of the first incident, the resident, who had been receiving OT and PT and was preparing for discharge home, was engaged in a simulated laundry task with a COTA. The resident was filling a basket attached to her walker when the basket came loose. As the COTA attempted to adjust the basket, the resident stepped back on her unsupported right leg, lost her balance, and fell backward. She was wearing a gait belt and non-skid socks but was not wearing the ordered hinged knee brace locked in extension. Following the fall, she complained of severe right knee pain and was unable to move the knee. Imaging later revealed a nondisplaced fracture of the proximal tibia and fibula, a tear of the medial meniscus, hemarthrosis, and swelling. The facility’s investigation concluded that the resident was not wearing her physician-ordered hinged brace, locked in extension, at the time of the accident, despite the brace requirement being present on the passport and in physician documentation. The second incident involved another resident with multiple diagnoses including a right femur fracture, history of falls, anticoagulant use, and moderately impaired cognition. This resident had been assessed as high fall risk, had an active fall risk protocol with frequent safety rounding, and required partial/moderate assistance with toileting and toilet transfers. The resident’s door displayed red rounding signage and a fall-risk star, and staff interviews confirmed that high fall risk residents were not to be left unattended on the toilet. On the day of the fall, a PTA transferred this resident onto the toilet, placed the call light across her lap, instructed her to pull it when finished, and then left the room to treat another resident without notifying a nurse or CNA that the resident was on the toilet. The PTA reported not seeing the fall-risk sign on the door. Shortly thereafter, a CNA responding to the call light found the resident on the bathroom floor with head and ear injuries. An ARNP assessed her and she was sent to the hospital, where a CT scan showed a subarachnoid hemorrhage in the right posterior temporal lobe. The facility’s investigation determined that the PTA left a known high fall risk resident unattended on the toilet and failed to recognize posted fall-risk signage and the requirement for stand-by supervision while toileting. Across both events, the facility did not ensure that therapy staff consistently used available tools and information—such as the passports, EMR precautions, and door signage—to follow physician orders and care plan interventions related to fall prevention and orthotic use. Therapy staff had access to the EMR and passports, which contained key information on weight-bearing status, orthotic devices, and fall precautions, yet in one case the brace order was not incorporated into therapy precautions before the fall, and in the other case the PTA did not heed the fall-risk indicators or the facility’s bathroom safety expectations. These failures resulted in two serious fall-related injuries and were determined by surveyors to constitute neglect and Immediate Jeopardy, with potential risk to all residents requiring orthotic devices and all residents on active therapy caseload.
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