Failure to Follow High-Risk Fall Interventions and Timely Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to follow established fall-prevention interventions and care plan directions for a resident identified as a high fall risk. The resident was admitted with multiple diagnoses including COPD, hypertension, anxiety, metabolic encephalopathy, vertebral compression fracture, bone disorders, history of falls, femur fracture, atrial fibrillation, hypothyroidism, lack of coordination, UTI, and cirrhosis. An MDS showed the resident was cognitively intact but required maximal assistance with toileting hygiene and moderate assistance with transfers. The resident’s fall risk care plan, initiated at admission and updated after a prior fall, identified her as at risk for falls related to weakness, fatigue, activity intolerance, pain, and history of falls, and included interventions such as staff assessing and anticipating ADL and toileting needs during rounds, providing timely incontinence care, making frequent safety rounds, and maintaining bilateral safety mats at the bedside. On the night of the fall, the resident activated the call light because her incontinence brief and bed sheets were wet and requested incontinence care. The CNA who responded told the resident she would return after completing another task, then proceeded to deliver ice water to another resident, obtain sheets from the linen cart, and go to another floor to obtain incontinence briefs. During this delay, the resident, who was known to be a high fall risk and required assistance with toileting and transfers, attempted to get to her wheelchair to use the bathroom independently and fell forward. The resident later reported she used her cell phone to call the facility to notify staff of the fall and that she had sustained a skin tear on her left arm and was experiencing back pain. The next morning, a pulmonary nurse assessed the resident and found her confused compared to baseline, with a protruding hematoma on the right forehead and a skin tear on the left upper extremity. The resident reported she had fallen the previous night and had back pain. The DON confirmed the fall was unwitnessed, that the resident was on high fall risk precautions, and that staff were expected to follow the care plan and immediately attend to the resident’s incontinence needs. The DON also stated that at the time of the fall, only one fall mat was in place on the right side of the bed, while the resident’s care plan called for bilateral safety mats, and the resident had fallen from the left side where no mat was present. The facility’s fall prevention policy required universal fall precautions, individualized high-risk interventions, purposeful rounding to address toileting and incontinence needs, and adherence to high-risk fall precautions, which were not followed in this incident.
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