Failure to Implement Fall Precautions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement effective fall precaution interventions for a resident identified as high risk for falls. The resident had multiple diagnoses including unspecified dementia, Alzheimer’s disease with late onset, cerebral infarction, orthostatic hypotension, repeated falls, unsteadiness on feet, osteoporosis, and adult failure to thrive. The MDS documented severe cognitive impairment with memory problems, substantial/maximal assistance needs for ADLs, partial/moderate assistance with mobility, bowel and bladder incontinence, and wheelchair use. The resident’s fall care plan identified high fall risk related to impaired mobility, poor safety awareness due to confusion, history of falls, and a recent fall, and included preferences for the bed to be kept in the lowest position and for a safe environment, with floor mats/floor pads at bedside “if appropriate.” Fall risk assessments documented high fall risk scores. On the day of the fall, progress notes show the resident was wheeled by staff to the dining room to participate in activities with staff supervision and later required transfer to the hospital for a laceration to the left eyebrow that required five sutures. The facility-reported incident documented that the resident fell in the facility and sustained this laceration. A registered nurse later stated she reviewed video footage showing the resident eating in the dining room, appearing to become dizzy, and then falling out of the chair, hitting her head on the floor and bleeding. The RN stated staff were present in the dining room but were busy doing other tasks and were unable to prevent the fall. During the survey, the resident was observed in the dining room in a wheelchair and later in bed. The bed was observed in a high position, not in the lowest position as specified in the care plan, and there were no floor mats in place while the resident was in bed. An agency CNA assigned to the resident stated she was not aware of the resident’s specific fall precaution interventions, noted the bed was not in the lowest position, and reported that when she started her shift the resident did not have floor mats in place. The fall coordinator/restorative nurse confirmed responsibility for entering fall interventions into the care plan, stated that care plans are updated after falls, and that all fall interventions are expected to be followed once implemented. She acknowledged that the care plan language for floor mats said “if appropriate,” that she had determined the resident was appropriate for floor mats, and that the care plan required the bed to be in the lowest position while in bed. The facility’s fall policy stated that residents at high risk for falls will be provided fall interventions and that interventions are to be added to the care plan and implemented.
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