Failure to Maintain Secure Lap Tray and Update Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement effective safety measures to prevent falls for a resident with known fall risk and severe cognitive impairment. The resident, who has diagnoses including cerebral palsy, seizure disorder, dependence on a wheelchair, muscle disorder, and intellectual disability, was care planned as having potential for falls due to confusion, deconditioning, gait/balance problems, incontinence, poor communication/comprehension, and unawareness of safety needs. The care plan included use of a lap tray while the resident was up in her chair to prevent falls and ensure safety. On one occasion, the resident was found lying on her back/right side on the dining room floor next to her wheelchair, with no apparent physical injury at that time. Subsequent hospital evaluation included a CT of the head and urinalysis, and the resident was later returned to the facility. Staff observations and interviews revealed that the lap tray used as a fall-prevention intervention was not secure and was known by staff and family to loosen, lift, and slide off when the resident moved in the wheelchair, allowing the resident to slide out of the chair. A CNA reported returning from break to find the resident on the floor in the dining room, stating that the resident had the lap tray on but it was not secure and that she was sure the loose tray caused the fall, although she did not witness the fall. A later observation showed the resident in the dining room with a clear plastic lap tray attached to the wheelchair armrests by Velcro straps, with the tray easily moved and sliding up and down. Despite the fall and the known issue with the loose tray, there were no new interventions implemented in the resident’s care plan following the fall, and the facility’s fall reduction policy called for providing an environment as free of accident hazards as possible and developing appropriate interventions to prevent or minimize fall-related injuries.
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