Failure to Implement Care-Planned Fall Interventions Leads to Serious Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure that fall prevention strategies were assessed and implemented for a resident at high risk for falls, resulting in a fall with multiple serious injuries. The resident had dementia, vertebral and sacral fractures, age-related osteoporosis, lower extremity impairments bilaterally, frequent urinary incontinence, and a history of falls and fractures. The resident’s MDS and fall risk assessment identified moderate cognitive impairment, unsteadiness, inability to independently stand, and the need for hands-on assistance and a mechanical stand for transfers. The care plan documented specific fall interventions, including keeping the call light within reach, maintaining the bed in the lowest position with a fall mat in place when the resident was in bed, and ensuring gripper socks were worn at all times. In the weeks preceding the fall, staff observed changes in the resident’s behavior and mobility. Progress notes indicated that the resident had previously fallen while attempting to ambulate independently wearing compression stockings, with the root cause identified as slipping on the floor and an intervention added to place gripper socks over compression stockings. Staff interviews revealed that, although the resident was typically content lying in bed, in the weeks before the incident she had begun making attempts to get out of bed and had been found seated on the side of the bed on several occasions. These observations indicated increased impulsivity and attempts at self-transfer in the context of dementia and impaired safety awareness. On the day of the incident, the resident was placed in bed by a nursing assistant who did not lower the bed or place the fall mat, and the resident was left in stocking feet without gripper socks, contrary to the care-planned interventions. The resident subsequently attempted to get out of bed, fell between the bed and recliner, and was found on her side with her right leg twisted underneath her, her left arm pinned, and a large pool of blood around her head. The bed was observed in a raised position with no fall mat in place. The resident sustained a scalp laceration, right tibial plateau fracture, right femur fracture, and a bimalleolar fracture of the right ankle, and experienced severe pain and swelling in the right leg, requiring evaluation and imaging in the emergency department and hospitalization for management of multiple fractures and acute head injury.
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