Two residents experienced multiple falls due to inadequate supervision and lack of updated interventions. Despite having care plans in place, the facility failed to implement new strategies following each incident, contributing to ongoing fall risks. The DON and Administrator acknowledged the issues but did not provide evidence of effective follow-up actions.
A resident with a history of recent hip fracture, confusion, and multiple comorbidities experienced a fall with injury after staff failed to implement care planned fall prevention interventions, including use of positioning wedges, floor mat, and proper bed height. The resident was found on the floor with injuries, and documentation and staff interviews confirmed that required interventions were not in place at the time of the incident.
A resident who was at risk for falls and required extensive assistance was found on the floor after fall prevention interventions, including bilateral fall mats, were not in place as specified in the care plan. Observation later confirmed that the required fall mats were still not present, and the DON acknowledged this omission.
Two residents with a history of falls and major injuries did not receive appropriate fall prevention interventions as outlined in their care plans. One resident, with conditions like Metabolic Encephalopathy, was not provided with hipsters or Dysem, leading to a fall and fracture. Another resident, with Hemiplegia, lacked floor mats by the bed, resulting in a fall and femur fracture. Staff were unaware of these interventions, and there was no documentation verifying their implementation.
Two residents in an LTC facility were not adequately supervised, leading to safety risks. One resident with dementia wandered unsupervised, entering other residents' rooms and attempting to open exit doors. Another resident with Huntington's Disease experienced multiple falls due to unclear care plan documentation and lack of assistance during ambulation. Staff interviews revealed challenges in managing these issues due to limited staff availability and communication gaps.
A resident with Parkinson's disease and dementia, identified as high risk for falls, experienced a fall resulting in injuries due to the facility's failure to follow the fall prevention interventions outlined in their care plan. The interventions, which included keeping the bed in the lowest position and placing a thick floor mat next to the bed, were not in place at the time of the incident. An agency CNA unfamiliar with the resident's needs was responsible for their care at the time.
A resident with significant mobility and cognitive impairments experienced multiple falls while attempting to use the bathroom independently. Despite care plans outlining fall prevention strategies such as regular toileting, use of call lights, and environmental safety measures, documentation showed inconsistent implementation and follow-through by staff. Gaps in providing timely assistance and unclear documentation contributed to repeated incidents.
A resident with severe cognitive impairment and a history of falls was inadequately supervised during toileting, contrary to the care plan requiring two staff members. The CNA assisting the resident was unfamiliar with the facility's care instructions, leading to multiple falls. Despite care plan updates, interventions were not effectively communicated or implemented, contributing to the resident's repeated accidents.
A resident with impaired cognition, osteoporosis, osteoarthritis, restless leg syndrome, and a high fall risk had a care plan that included floor mats on the sides of the bed. During observation, the mats were found propped against the wall while the resident was lying in bed. An LVN, CNA, PT, and DON all stated the mats were intended to be alongside the bed when the resident was in bed because the resident had a history of unassisted attempts to get up and was at increased risk for injury if the mats were not used.
A resident at Wyncote Care Center fell from bed during a linen change due to improper technique by a nurse aide. The resident, who required substantial assistance for transfers, was turned away from the aide, leading to a fall when her hands slipped off the side rail. The incident resulted in severe right-side pain, and the resident was transported to the hospital for evaluation.
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