Failure to Follow Care Plan and Provide Required Assist During Ambulation, Resulting in Fall
Penalty
Summary
The facility failed to ensure an area was free from accident hazards and to provide adequate supervision to prevent a fall for one resident. The resident was admitted with a history of falling, a humerus fracture, and joint replacement surgery. The admission MDS showed the resident was cognitively intact and required touching assistance with one helper and use of a 2‑wheeled walker for ambulation, as documented in the care plan initiated in mid‑December. Facility staff, including the RN and DON, described "touching assistance" as requiring staff to touch, guide, and maneuver the resident while using a gait belt. On the date of the incident, nursing documentation recorded that the resident was found on the floor at the foot of the bed after attempting to transfer from bed to walker and reported trying to get to the walker. A fall incident report documented the event as unwitnessed, but also recorded the resident’s statement that she was ambulating to the bathroom using her walker with a CNA present when she lost her balance. In interviews, the DON reported that the CNA assisted the resident to a standing position and then left the resident standing while going into the bathroom to get things ready, after which the resident fell. Another CNA reported arriving at the tail end of the fall, seeing another aide lowering the resident to the floor, with a walker present but not really being used and no gait belt in place. Staff interviews and record review confirmed that, contrary to the care plan, the resident was left standing alone without the required touching assistance, gait belt use, and proper use of the walker at the time of the fall.
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