Failure to Implement Fall-Prevention Measures and Maintain Accessible Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall-prevention interventions and adequate supervision for four residents identified as being at risk for falls. One resident was admitted with multiple diagnoses including encephalopathy, diabetes, cardiomegaly, nicotine dependence, and a history of falling, and was assessed as a moderate fall risk on the day of admission. He had no care plan in place because he discharged the same day, yet nursing notes show he was transferred to bed with existing bruises and a scabbed right knee, and later found face down on the floor with a pool of blood, lacerations to his eyebrow and nose, and a reopened knee abrasion, requiring transfer to the emergency room. Staff interviews revealed that this new admission was allowed to sit on the side of the bed to eat, unclothed except for socks, without use of a mechanical lift or other fall-prevention measures, despite staff acknowledging that new residents are typically transferred with a mechanical lift until therapy evaluates them and that he had a history of falls. Additional deficiencies were identified for three other residents with documented fall risks and care plans requiring that call lights be within reach. One resident with pneumonitis, sepsis, acute respiratory failure, anxiety disorder, restlessness, agitation, and bipolar disorder was assessed as high risk for falls and had a care plan directing that his call light be within reach and used for assistance. During observation, his call light was on the floor at the foot of his bed and not accessible, and floor mats that were part of his fall-prevention interventions were not in place at his bedside but instead folded and stored near his roommate’s bed. Facility accident/incident logs showed this resident had prior falls on two separate dates. Two other residents, both with dementia and additional diagnoses including Alzheimer’s disease, depression, anxiety disorder, osteoporosis, difficulty in walking, and a need for assistance with personal care, were also observed with their call lights on the floor and out of reach, despite care plans and fall scales indicating moderate to high fall risk and specifying that call lights should be within reach and used for assistance. The facility’s Fall Prevention and Management Policy required that interventions be implemented for residents assessed as high risk at admission for up to 72 hours and that all staff observe residents for safety. Observations and interviews showed that these interventions, including accessible call lights and appropriate environmental safety measures, were not consistently implemented or maintained for these residents.
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