Failure to Follow Care-Planned Fall Prevention and Transfer Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions and transfer methods for multiple residents identified as being at risk for falls. The facility’s fall prevention policy requires standardized fall risk assessments, categorization into risk levels, and implementation of individualized interventions based on high- or low/moderate-risk protocols, with ongoing monitoring and care plan revision. Despite this, surveyors found that for several residents, the interventions and transfer methods specified in their comprehensive care plans were not followed in practice. For one resident with significant ADL dependence, incontinence, and a history of a fall with major injury and pelvic fracture, the comprehensive care plan specified that all transfers were to be done with a Hoyer lift. Progress notes and incident documentation showed that this resident was instead transferred from the toilet to a wheelchair by a nursing assistant without a gait belt, contrary to the care plan. The resident fell during this transfer, complained of pain, and was later found to have a closed fracture of the pelvis. The DON confirmed that the resident had not been transferred properly and that the pelvic fracture resulted from this event. Another resident, who required total assistance with transfers, toileting, hygiene, dressing, bed mobility, and bathing, had a care plan identifying a high fall risk with a fall risk score of 15 and multiple fall prevention approaches, including use of a fall mat next to the bed and a fall alarm when in bed. During observation, this resident was found lying in bed with the fall mat leaning against the wall at the foot of the bed and no fall alarm in place. The nursing assistant confirmed that the fall mat was not next to the bed and that the fall alarm had not been moved from the wheelchair to the bed as required. A third resident, cognitively intact but requiring assistance with transfers and occasionally incontinent, had a fall risk score of 13 and a care plan specifying transfer to the bathroom by wheelchair with a gait belt and use of blue Dycem between the wheelchair seat and gel cushion to prevent slipping. Observations showed the resident being ambulated to the bathroom with a walker and gait belt instead of being taken by wheelchair, and the blue Dycem was absent from the wheelchair. The nursing assistant involved stated they were not aware the resident was to be taken to the bathroom by wheelchair, and the DON confirmed the resident should not have been ambulated.
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