Failure to Implement and Communicate Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and consistently follow fall-prevention interventions as outlined in residents’ care plans. One resident with dementia, multiple neurological conditions, and on numerous psychoactive and anticonvulsant medications had a history of falls from bed and from a wheelchair. After falls in which the resident became entangled with wheelchair foot pedals and struck her head, the interdisciplinary team determined that the wheelchair foot pedals should be removed and non-slip material placed on the wheelchair seat. However, the resident’s care plan contained conflicting information: the Resident Care Information section continued to require bilateral foot pedals on a high-back reclining wheelchair, while the Fall Risk section directed that the foot pedals be removed. The non-slip material intervention was not documented in the care plan. During observation, the resident was transferred into her wheelchair with no non-slip material present on the seat or under the padded cushion, despite the team’s prior decision to use it. A staff member later acknowledged carrying non-slip material intended for this resident’s wheelchair and stated she had revised the care plan to include it, but the care plan still listed foot pedals in one section and removal of foot pedals in another. The staff member also confirmed that the intervention to remove the foot pedals should have been revised in the Resident Care section of the care plan, and the administrator stated that care plan interventions recommended by the interdisciplinary team are expected to be implemented into the care plan. A second resident with encephalopathy, dementia with agitation and psychotic disturbance, Parkinsonism, seizures, osteoporosis, and other conditions, and who was receiving anti-Parkinson’s, antipsychotic, and multiple anti-seizure medications, experienced multiple falls in her room. Documentation showed one fall occurred when the resident was barefoot and looking for a bathroom, another when she was wearing non-skid slippers, and additional falls occurred with an orthopedic boot in place or with no documentation of footwear. Observation later found this resident seated in a high-back wheelchair with regular dress socks and her left foot dangling between the two foot pedals. A LPN stated the resident attempts to stand without assistance and should be wearing non-slip socks, and the DON indicated she would need to determine the status of non-slip socks for this resident, noting recent use and discontinuation of an orthopedic boot and initiation of hospice services.
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