Failure to Provide Required Assistance and Implement Care-Planned Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate assistance with bed mobility and to implement care-planned fall interventions for residents at risk for falls. Resident #6, admitted with a history of cerebral infarction and resulting hemiplegia/hemiparesis, had a Minimum Data Set (MDS) showing severe cognitive impairment (BIMS score of 0) and dependence on staff for toileting hygiene and rolling in bed. The resident’s care plan, initiated shortly after admission, directed staff to provide two-person assistance with bed mobility and to keep the bed in the lowest position while the resident was in bed. Despite this, a progress note documented that the resident fell during activities of daily living care. An LPN reported that a GNA pulled the resident to turn them in bed and the resident rolled off the bed; the GNA stated she believed the resident was a one-person assist and described releasing contact with the resident to retrieve an incontinence brief, after which the resident began to roll and she eased the resident to the floor. The ADON, another LPN, the DON, and the Administrator all stated that Resident #6 required two-person assistance for bed mobility and that two staff should have been present during such care. The facility also failed to implement fall interventions that were included in Resident #6’s care plan. The care plan for Resident #6, updated after a recent hospitalization and fall risk identification, included interventions to place fall mats on both sides of the bed and to maintain the bed in the lowest position while the resident was in bed. Multiple observations of the resident’s room on different days showed that fall mats were not present on either side of the bed and that the bed was not in the lowest position, despite these interventions being listed on the care plan. During interviews conducted concurrently with these observations, a GNA and the ADON acknowledged that fall mats were not in place and that the bed was not in the lowest position, even though the care plan required these measures. Resident #4, admitted with hemiplegia, muscle weakness, cerebral infarction, and lack of coordination, was also care-planned as being at risk for falls related to weakness, hemiplegia, and a recent hospitalization. The resident’s care plan included an intervention to place fall mats at the sides of the bed. However, during observations on multiple occasions, Resident #4 was seen in bed without fall mats present. In concurrent interviews, a GNA and the ADON confirmed that fall mats should have been in place according to the care plan but were not. The DON and the Administrator both stated they expected fall interventions to be implemented, yet the observations showed that the planned fall-prevention measures for Resident #4 were not carried out.
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