Failure to Maintain Care-Planned Fall Precautions and Call Light Accessibility
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain fall precautions and accident prevention measures as care planned for multiple residents. One resident with moderately impaired cognition, hallucinations, and alcohol-induced persisting dementia was observed lying crosswise in bed without the ability to rise and without a call light within reach, despite a care plan intervention directing staff to ensure the call light was within reach and to encourage its use. Another resident, who was rarely or never understood and had diagnoses of seizures and dementia with behavioral disturbance, was also observed lying in bed without a call light in reach, contrary to a care plan intervention requiring the call light to be kept within reach and used for assistance as needed. A third resident, also rarely or never understood and diagnosed with dementia with behavioral disturbances, was observed lying in bed with the call light located between the wall and the bed, out of reach, despite a care plan intervention to keep the call light within reach and encourage its use. A fourth resident, with intact cognition but with a history of cerebral infarction and hemiplegia/hemiparesis, reported having fallen while trying to transfer independently; surveyors observed that grip strips were not present on the bathroom floor or in the shower room, even though the resident’s care plan included interventions to apply grip strips in both areas with specific initiation dates. CNAs interviewed stated that fall precautions are found in the medical record and that residents should have call lights within reach, and the Director of Nurses stated she expected all fall interventions to be in place. The facility’s Fall Prevention Program policy required safety interventions to be implemented and consistently maintained for residents at risk, but these interventions were not in place for the residents reviewed.
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