Inadequate Supervision Leads to Multiple Falls in High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision for two residents who were at high risk for falls, leading to multiple incidents. Resident #2, who had a history of senile degeneration of the brain, major depressive disorder, and reduced mobility, was found with bruising and a clavicle fracture after a fall that was not reported by a staff member. Despite being identified as a high fall risk, no interventions were implemented after the first fall, and the care plan was not updated to reflect necessary fall prevention measures. This lack of action resulted in another fall where the resident was found on the floor, requiring assistance from multiple staff members to return to bed. Resident #3, diagnosed with hereditary ataxia, cerebral palsy, and dementia, also experienced multiple falls. After being found on the floor on two separate occasions, the resident suffered significant injuries, including a subarachnoid bleed and facial trauma. Despite being a high fall risk, the resident was left unsupervised in common areas and in her room, contrary to the facility's policy that required supervision for residents with a high fall risk score. The care plan was not updated with appropriate interventions after each fall, contributing to the repeated incidents.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility is credible allegation of compliance. 1. Risk evaluations completed for Resident #2 and Resident #3. Appropriate revisions were made to the care plans to reflect all current interventions. 2. Risk Evaluation completed for all residents currently residing in the facility by Care plans reviewed and revised as indicated for residents identified as at risk for to make certain interventions are documented for each and are reflected on the Kardex. 3. Regional Director of Clinical Services/Designee educated staff on Accidents and Supervision policy; Prevention in Long Term Care; and Resident Rights with emphasis on the development and implementation of a person-centered care plan. Licensed staff educated on Prevention Program and reviewing the Kardex for interventions. 4. Director of Clinical Services (Nursing)/Designee will review new admission records for initiation of Baseline Care Plan to make certain those identified to be at risk for have interventions/safety measures, five times a week x 4 weeks and once weekly x 8 weeks, then as needed as indicated. Director of Clinical Services/Designee will review records of residents who sustain to make certain documentation includes Change in Condition, Physician Notification, Responsible Party Notification, Care Plan Update with intervention and placement on Kardex five times a week X 2 weeks; three times a week X 4 weeks, twice a week X 2 weeks, then weekly x 4 weeks, and as needed as indicated. The findings of these quality reviews are to be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months, or until committee determines substantial compliance.