Failure to Individualize Fall Prevention for Hemiplegic Resident Leading to Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and individualized care planning for a resident with left-sided hemiplegia and hemiparesis. The resident’s care plan, dated 12/8/2025, identified a risk for falls related to impaired mobility and a history of CVA and included interventions such as nonskid socks, clutter-free environment, adequate lighting, low bed, call light within reach, and reorientation as needed due to dementia. However, the care plan did not address the resident’s specific physical limitation by directing staff to place personal items and belongings on the resident’s right (unaffected) side for safe and easy access. The facility’s fall management policy stated that the facility would maintain an environment free of accident hazards and provide adequate supervision and assistive devices to prevent avoidable accidents. On the day of the incident, the resident’s roommate activated the call light, and staff later found the resident on the floor between the B-bed and C-bed in a three-bed room. The bedside table was observed tilted and pushed against the B-bed, and the resident had a bump and superficial scrape on the right forehead with a moderate amount of blood. The resident reported reaching for the remote control on the bedside table, feeling weak, and then falling to the floor. The DON stated that the facility’s investigation determined the bedside table had been placed on the resident’s affected side, making it difficult for the resident to reach needed items. CNA 1 acknowledged knowing the resident had left-sided weakness and that the bedside table should have been on the right side, but could not recall the table’s position before leaving for a 30‑minute lunch break and did not inform the covering CNA of her absence. The resident was transferred to the hospital, where a superficial forehead laceration was sutured and a femoral neck fracture was diagnosed.
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