Improper Stand Aid Use and Delayed RN Assessment After Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and proper use of assistive devices to prevent accidents for a cognitively impaired resident with a high fall risk. The resident had a BIMS score of 6/15, indicating severe cognitive impairment, and a care plan identifying self-care deficits related to polyneuropathy, frequent falls, failure to thrive, weakness, and decreased mobility, with interventions including high fall risk precautions. The care plan specified use of a stand aid with assist of one staff for transfers and assist of two staff for toileting at specified times and intervals. Despite this, a CNA entered the resident’s room to provide incontinence care and used the stand aid alone, without a second staff member, to assist the resident to a standing position. While the resident was standing in the stand aid, the CNA attempted to pull down the resident’s pants to change the incontinent brief, during which the resident stated they could no longer stand and their feet slipped off the stand aid platform. The CNA was unable to reposition the resident’s feet and lowered the resident to the floor. Following the fall, another CNA noticed the closed door, entered the room, and called an LPN, who assessed the resident; the resident was then returned to bed using a Hoyer lift. Later that evening, the resident reported right ankle/foot pain, and an RN assessed the resident and obtained provider orders for x‑rays. Two days after the fall, the resident was sent to the ER for x‑rays and was found to have an acute comminuted, minimally displaced, extra‑articular fracture of the right posterior calcaneal tuberosity. The report notes that an RN did not assess the resident until six hours after the fall, following the initial LPN assessment. Interviews with staff indicated that CNAs understood that if a care plan required assist of two for toileting, they would not use the stand aid alone for incontinence care, and the Rehab Director stated the stand aid was only to be used for transfers, not for standing a resident for incontinence product changes. The Nursing Home Administrator acknowledged the expectation that staff follow the plan of care and that the CNA should have had assistance for the resident’s incontinence care. The report also states the facility did not provide education for staff and did not interview other residents.
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