Failure to Prevent Falls and Ensure Safe Transfers for Residents at Risk
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and assistance to prevent falls for two residents with dementia and documented fall risks. One resident had severe cognitive impairment, a history of falls, and was assessed as high risk for falls over multiple months. Her MDS and care plans showed a progression from independence with transfers and ambulation to requiring staff assistance with transfers, limited ambulation, and use of a wheelchair, with specific care plan directions that staff should provide assistance with transfers, offer a wheelchair, ensure non-skid footwear, provide non-slip strips in front of her recliner, and keep staff close when she was alone. Despite these identified risks and interventions, she continued to ambulate with heavy bags and purses, and staff reported she was very unsteady, could not walk long distances, and required a staff member to walk with her. This resident experienced multiple falls. In one incident, she was found on the floor in a hallway with two full purses and a book next to her, with a large hematoma on her forehead and hand, and was later diagnosed with a left wrist fracture. A post-fall root cause analysis identified that she had been carrying extremely heavy bags, which contributed to her loss of balance and fall. In a later incident, she fell in a living room area described as highly congested, with furniture and other residents present. Staff reported she lost her balance and fell on her left side, and she was later admitted to the hospital with a left hip fracture. Facility documentation of this fall was inconsistent: the facility’s reportable incident form stated she tripped on another resident’s foot while walking between furniture and other residents, while witness statements from a nurse and a CNA indicated they heard or saw her fall but did not clearly document a witnessed fall. The facility’s investigation also lacked documentation that available video footage was reviewed, even though an administrative staff member later stated she had watched the video and determined the resident tripped over another resident’s foot. The second resident involved in the deficiency had dementia, abnormal gait and mobility, and a history of multiple falls since admission. Her care plan identified her as at moderate risk for falls related to safety awareness and dementia, but it initially lacked specific direction to staff regarding transfer technique. During a one-person pivot transfer from a recliner to a wheelchair, her knees buckled and she fell to the floor, landing on her right knee and left cheek. Subsequent nursing documentation reviewing the fall stated that the staff member performing the transfer was not using a gait belt at the time of the incident. Only after this fall was an intervention added to the care plan specifying that she should be transferred with a two-person assist and a gait belt. Administrative nursing staff later confirmed that the resident had been transferred without a gait belt, which caused her to fall, despite the facility’s falls policy stating that residents at risk for falls would have interventions implemented and documented on the comprehensive plan of care.
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