Failure to Supervise, Safely Position, and Timely Evaluate a Resident After a Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision, safe transfer and positioning practices, post-fall assessment, and timely medical evaluation for one resident. Facility policies on assisting with bed mobility require that residents not be left on the edge of the bed and that staff ensure the resident is in the middle of the bed with the bed lowered to reduce injury risk. The Falls and Fall Risk policy requires staff to identify and implement interventions to minimize serious consequences of falls. Despite these policies, the resident’s care plan did not include interventions for safe positioning during care, staff positioning, remaining with the resident during care, or documentation of the resident’s ADL abilities and required number of staff for care. The resident’s therapy records documented extensive assistance needs with ADLs, dependence on staff for transfers requiring a mechanical lift, poor trunk control, need for two-person assistance for sitting, and non-ambulatory status. On the date of the fall, a CNA reported turning the resident onto his side for care and then stepping away to retrieve supplies, leaving the resident unattended on his side. The CNA stated that upon returning, she observed the resident coughing and rolling off the bed, and although she attempted to stop the fall by grabbing the resident’s upper body, the resident fell completely to the floor. Staff then lifted the resident from the floor without using a mechanical lift because they reported being unable to get the lift into the area where the resident was lying. Following the fall, the facility’s incident note documented only minor scratches and no complaints of pain, and nursing notes over the next days recorded administration of PRN Tylenol and Tramadol for general discomfort and back pain. No physician evaluation or diagnostic imaging was obtained at that time. A week later, the resident complained of rib pain and was sent to the emergency room, where CT imaging revealed new rib fractures and an L2 compression fracture not present on prior studies, along with scattered bruising worse on the left side. Hospital staff documented that facility staff reported the fall had occurred a week earlier with no intervening physician evaluation or imaging. Interviews with the DON, ADON, and CNA supervisor revealed they did not ensure CNA access to or use of care plans, were unaware of an ADL care plan for the resident, and acknowledged that the care plan lacked ADL and safe care information, and that the CNA who provided care did not usually work on that unit and would not have been familiar with the resident’s needs.
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