Failure to Implement Fall Interventions and Complete Thorough Fall Investigation
Penalty
Summary
The deficiency involves the facility’s failure to ensure fall interventions were in place and to conduct a thorough fall investigation for a resident with significant cognitive and physical impairments. The resident, admitted with diagnoses including vascular dementia, anxiety, osteoarthritis of the right shoulder, congestive heart failure, contracture of the right hand, dysphagia, and depression, had impaired cognition and was dependent on staff for bed mobility, transfers, and ambulation. The resident’s care plan and fall risk assessment identified a high risk for falls, with interventions including nonskid socks at all times, a low bed, the bed placed against the wall, and a fall mat to the floor next to the bed. Physician orders also included a mat to the left side of the bed, bilateral grab bars, and assistance out of bed early in the morning. On the evening of the incident, staff reported that the resident had been put to bed with the bed in the lowest position and a bolster on the left side due to the order for the bed to be against the wall. Later that evening, staff heard a scream and entered the room, finding the resident on the floor in a pool of blood, actively bleeding from the right side of the forehead and nose, and the bed in a medium position. A cognitively impaired resident who wandered into other residents’ rooms and played with bed remotes, and who was care planned for frequent wandering and combative behavior with redirection, was in the room at the time of the incident. However, the progress note did not document that this wandering resident was present. The fall investigation contained witness statements from the DON and one CNA, but lacked statements from other staff who were working at the time, including the RN who discovered the resident and additional CNAs. The risk report listed predisposing environmental factors as “other” without describing them, did not document whether the fall mat was in place, and did not record that the wandering resident was found in the room or that this resident was care planned for wandering and combative behavior. The DON confirmed there was an order for a mat to the floor that was not in place at the time of the fall and verified that the fall investigation lacked required information.
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