Inadequate Supervision Leads to Recurrent Falls
Penalty
Summary
Sunset Ridge Rehabilitation and Nursing Center was found to be non-compliant with federal and state regulations due to inadequate safety measures and supervision for a resident identified as high risk for falls. The facility failed to implement effective fall prevention interventions, resulting in multiple recurrent falls for a resident with severe cognitive impairment and a history of impulsiveness and poor safety awareness. Despite being identified as high risk for falls, the resident experienced 14 falls over a period of several months, many of which were unwitnessed. The resident, admitted with diagnoses including dysphagia, abnormalities of gait and mobility, repeated falls, hypertensive heart disease, and urinary tract infection, continued to fall in various locations such as their room, bathrooms, and common areas. The facility's documentation revealed a lack of consistent implementation of planned interventions, such as frequent visual checks, which were added to the resident's care plan but not consistently conducted. The resident's falls resulted in injuries, including abrasions, hematomas, and a head wound, and were often associated with attempts to self-transfer or use the bathroom. Interviews with facility staff, including the Director of Nursing, confirmed the failure to provide adequate supervision and follow through with planned interventions. The facility's inaction and lack of effective supervision contributed to the resident's recurrent falls and injuries, highlighting a significant deficiency in meeting the required standards for resident safety and care.
Plan Of Correction
Resident 50 frequent visual checks evaluated and removed from tasks and care plan. Fall interventions reviewed and verified as effective. Facility will continue to implement interventions to assist with prevention of recurrence of falls/injury. Current residents care plans will be reviewed to verify presence of safety interventions to assist in the prevention of falls. Nursing staff will be re-educated on the implementation of effective fall prevention interventions. Audits will be completed on fall incident reports weekly x 4 weeks, then monthly x 2 months to ensure the implementation of fall prevention interventions. Results will be reviewed at monthly QAPI meeting.