Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent falls for a resident with a history of multiple falls. The resident, who was severely cognitively impaired and required maximal assistance to stand and transfer, was admitted with diagnoses including unsteadiness on feet and repeated falls. Despite these known risks, the resident was placed in a room far from the common areas and nurses' station, limiting the ability of staff to provide close supervision. On the night of the incident, the staffing on the resident's hall was limited to one nurse and one CNA for 21 residents, which was insufficient to meet the resident's needs for close supervision. The resident was found on the floor after an unwitnessed fall, having sustained a fracture to the right humerus and thoracic vertebrae. Prior to the fall, the resident exhibited increased agitation, poor safety awareness, and attempted to transfer without assistance, indicating a need for more frequent monitoring than was provided. Interviews with staff and family members revealed that the resident was known to be confused and restless, particularly at night, and required immediate response to his needs. Despite this, the facility did not implement additional measures to ensure the resident's safety, such as increased supervision or frequent checks, leading to the fall and subsequent injury.
Plan Of Correction
Element 1: Resident #100 no longer resides at the facility. Element 2: All residents have the potential to be affected by this deficient practice. A 100% audit of current residents with falls in the last 30 days was completed on 3/24/25 to ensure residents' current needs, have appropriate notification and care plans were updated as needed. Element 3: NHA and DON reviewed the Fall prevention policy on 3/17/25 and deemed it appropriate. The DON/designee will re-educate all licensed nurses on fall prevention policy prior to 3/24/2025. Any licensed nurses not re-educated by 3/24/25 will not work until re-education is completed. An Ad-Hoc QAPI meeting will be held on 3/20/25 to review fall reduction policies and the plan of correction. Medical Director reviewed. Element 4: DON/Designee will review newly admitted residents and residents with falls weekly during clinical meetings for three (3) months to ensure interventions were implemented and appropriate, and notifications completed. Results will be reported to QAPI, and audits will not be discontinued until substantial compliance is achieved. DON is responsible for achieving and sustaining compliance.