Failure to Implement Fall Prevention Measures and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify, evaluate, and eliminate fall hazards and to provide adequate supervision for a high fall-risk resident. The resident was found lying on his right side on the floor near the bathroom, wearing regular socks instead of non-skid socks. His wheelchair was positioned at the head of the bed with the bedside table in front of it, and he reported that he slid while walking to the bathroom because of the socks he was wearing. A nurse responded to the surveyor’s call for assistance, obtained vital signs, and performed a head-to-toe assessment, identifying an open area on the resident’s right lateral lower leg. Multiple CNAs stated that the resident was not able to walk and that his usual pattern was to self-transfer to his wheelchair, self-propel into the bathroom, and then self-transfer onto the toilet. Record review showed that the resident’s admission fall risk assessment documented a history of falls in the past three months, intermittent confusion, chairbound status, and incontinence. The falls care plan identified the resident as high risk for falls related to gait and balance problems, with interventions including anticipating and meeting his needs. The ADL care plan documented an ADL self-care performance deficit related to impaired balance and specified that transfers required supervision by one staff member to move between surfaces. Despite these identified risks and care plan interventions, the resident was not wearing appropriate non-skid socks and did not receive the supervision required for transfers, as his assigned CNA reported last rounding on him several hours earlier. The facility’s fall prevention and management policy called for universal fall precautions, standardized assessment of fall risk factors, and implementation of a fall risk care plan to address universal precautions and individual risk factors, which were not effectively implemented in this case.
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