Failure to Implement Care-Planned Fall Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall-prevention interventions for a cognitively impaired, high fall-risk female resident, resulting in a serious fall with injury. The resident’s fall risk assessment identified her as HIGH risk for falls, and her care plan, initiated on 2/1/24, documented that she was at risk for falls related to weakness, impaired gait and balance, and required assistance for bed mobility and transfers. Care-planned interventions included cues in the room to ask and wait for assistance, non-skid strips at bedside and in front of the toilet, a low bed, call light within reach, and floor mats to the right side of the bed. However, on observation of the resident’s memory care room after the fall, there were no posted signs instructing her to call and wait for help, no fall mats, and no non-skid strips at the bedside or in the bathroom. On the morning of the incident, staff found the resident on the floor next to her bed with severe right arm pain, and she was sent to the hospital where she was diagnosed with a comminuted right humerus fracture requiring surgical intervention. Multiple staff interviews showed inconsistent understanding of the resident’s fall risk status and transfer needs. An agency LPN and one CNA reported that the resident was a fall risk, had a history of self-transferring, and required one-person assistance with transfers, while another former CNA and another CNA believed the resident was independent and safe to self-transfer and did not recognize her as a fall risk. These CNAs stated they did not check, or did not think to check, the electronic health record for the resident’s fall risk status and transfer requirements. The DON and Administrator both stated that the resident was confused, had a history of falls and self-transferring, required staff assistance with transfers and supervision for safety, and that fall interventions should follow the resident when she transfers to a different room. Despite this, the care-planned fall interventions were not in place at the time of the fall.
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