Failure to Implement Fall-Prevention Interventions Resulting in Patellar Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain current fall-prevention interventions for one resident, resulting in a left patellar fracture. The resident had dementia, Alzheimer’s disease, weakness, severe cognitive impairment, used a walker, and required substantial to maximal assistance with bed mobility, transfers, and ambulation. The care plan identified the resident as at risk for falls due to diagnoses, cognitive deficits affecting safety awareness, need for ADL assistance, bowel and bladder incontinence, and use of psychotropic and potential opioid medications. The care plan documented fall interventions including a concave mattress, neon tape to the walker, keeping the walker at bedside, encouraging the resident to ask for assistance when ambulating, alternating call rounds with toileting offers, and using lighter weight pajamas at bedtime. On one date, facility documentation shows the resident was previously resting in bed in the lowest locked position and was later found on the floor lying on her left side with her head against the closet door, incontinent of bladder, with disheveled blankets suggesting she slid out of bed. The fall investigation identified that the resident slid out of bed and noted that a concave mattress was to be used as an intervention. A subsequent fall occurred days later, when the resident was again found on the floor on her left side near the closet, with a small hematoma to the back of the head and an abrasion to the left knee. Staff documented that the resident was able to bear weight but had an unsteady gait with a slight limp, and that she commonly attempted to get up on her own despite requiring assistance to get out of bed and ambulate. Following the second fall, nursing notes describe the resident as reluctant to ambulate, with stiff lower extremity ROM and inconsistent reports of pain location. An x-ray report initially mentioned a patellar fracture without clarifying whether it was old or new, and a reread by the radiologist confirmed an acute left patellar fracture, later specified as a transverse fracture of the patella with apex anterior angulation and articular surface step-off. Surveyor observations on a later date found that no concave mattress was on the resident’s bed; staff CNAs reported that the resident had a regular mattress and denied that a special mattress had been in place. The DON stated that interventions are to be implemented and care plans updated after every fall, and the MD stated that if a concave mattress was ordered after a fall, she would expect it to be in place. The DON also stated the facility did not have a fall prevention policy and provided an undated Accident/Incident Prevention document without a facility name, which generally stated that interventions are to be put in place when a resident is identified as high risk for accidents/incidents.
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