Failure to Implement Care-Planned Fall Prevention Interventions During Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to ensure that safety interventions were in place for a resident identified as being at risk for falls. The resident had multiple diagnoses including osteomyelitis, palliative care status, type 2 diabetes, heart disease, chronic kidney disease stage 3, hypertension, mild cognitive impairment, and lymphedema. Her care plan identified her as at risk for falls, with self-care deficits and a need for staff assistance with bed mobility, and included interventions such as using side rails for support and cueing her to grasp the side rail for positioning. A Restorative Nursing assessment documented that she was on a bed mobility program and would roll side to side during care and repositioning using side rails as needed, and that side rails were indicated as an enabler to promote independence. Despite this, staff interviews and observations confirmed that side rails were not in place prior to the fall, and the resident instead held onto the bedside table during care. On the date of the fall, a CNA reported providing incontinence care and rolling the resident to her side while the resident held onto the bedside table because side rails were not in place. The CNA stated that while reaching for a towel with one hand and maintaining one hand on the resident’s body, the resident let go of the bedside table, said she got weak, and rolled off the bed onto the floor on the right side, where the bedside table was located. The nurse on duty reported that when she entered the room after the fall, the floor mats were not on the floor and that she believed the resident hit her head on the bedside table. The fall incident report documented multiple injuries including a lump with swelling on the right forehead, right eye bruising, a chin abrasion, a small cut on the right elbow, a bruise and small cut on the right ring finger, and bruising to the left knee. Subsequent observation showed the resident in a large bariatric bed with a large dark purple/greenish bruise to the right eye/forehead area and a small laceration to the chin, with the bedside table on the right side of the bed and thick bilateral floor mats on the floor. The Restorative Nurse confirmed the resident should have had side rails for bed mobility, acknowledged that her strength varied day to day and that she should have something to hold onto when weak, and was unsure who was responsible for ensuring side rails were in place, despite the facility’s Management of Falls Policy requiring assessment of hazards and implementation of appropriate interventions to minimize fall risks.
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