Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident identified as high risk for falls. The resident, who had a history of numerous falls and was diagnosed with dementia, reduced mobility, and osteoarthritis, was not provided with the necessary monitoring or supervision. On the day of the incident, the resident stood up from their wheelchair in the dining room and fell, despite being on a care plan that included half-hourly monitoring and positioning close to staff. The incident occurred when the assigned Patient Care Technician was not in close proximity to the residents in the dining room, as required by the facility's policy. The technician was reportedly completing a monitoring sheet in the back of the kitchen at the time of the fall. Video surveillance confirmed that no staff was near the residents during the incident, and the technician admitted to not being attentive to the residents. Interviews with staff revealed a lack of awareness and adherence to the monitoring duties. The technician responsible for monitoring was not present, and other staff members were not aware of the resident's fall history or interventions in place. The Deputy Director of Nursing confirmed that the technician was not in close proximity to the residents, which was a requirement for their monitoring duty. Despite the incident, the investigation concluded that there was no cause to believe neglect occurred.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: The Interdisciplinary team met, reviewed, and updated the Care Plan for Resident #22 to ensure all interventions related to falls are in place. After physical therapy assessment and team discussion, a geri chair was provided to resident #22. Resident #22 is non-ambulatory and has no ability to transfer independently. This seating provided a stable and secure seating surface. Resident #22 continues to be placed in the Dining room for close monitoring when awake, and staff are reminded to be in close proximity when monitoring. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The Director of Nursing/Designee will ensure that staff assigned to the Dining Room for monitoring are attentive to all residents in the Dining area and positioned in the dining room within close proximity to the majority of the residents. The Educator/Designee will provide additional education to all staff on the "Fall Reduction and Injury Prevention Program" and protocols on how to adequately monitor the Dining Room to prevent falls and injury. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The Administrator, Director of Nursing, and Medical Director will review and revise, as needed, policies and procedures related to fall reduction and injury prevention. The Educator/Designee will provide additional education to all staff on the "Fall Reduction and Injury Prevention Program" and protocols on how to adequately monitor the Dining Room to prevent falls and injury. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Assistant Directors of Nursing/designee will audit 10% of the Dining rooms on all 3 shifts to ensure assigned staff are attentive and within proximity of residents in the dining room on a weekly basis for 3 months or until improvement is sustained to ensure that staff are appropriately monitoring residents to prevent falls and accidents. The Director of Nursing/designee will report findings to the Facility Quality Assurance/Performance Improvement Committee on a monthly basis for evaluation and follow-up to ensure 100% compliance. Additional corrective actions will be implemented as needed. 5. Responsible Individual: Director of Nursing