Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement effective individualized interventions to prevent falls for two residents identified as high risk. One resident, who had right-sided paralysis, severe cognitive impairment, and was dependent on staff for repositioning, was frequently observed leaning to the left against a side rail in bed. Despite staff awareness of this behavior and the resident's inability to reposition himself, the care plan did not address these specific risks. The resident experienced an unwitnessed fall from bed, resulting in a nasal fracture and lacerations requiring emergency department treatment and sutures. Staff interviews confirmed that the resident's positioning issues and use of the electric bed were known, but interventions were not updated to address these hazards. Another resident, with diagnoses including Alzheimer's disease, dementia, and impaired mobility, was assessed as needing staff supervision to ambulate more than 50 feet and had known behaviors of putting herself on the ground. Despite these risks, the resident was allowed to ambulate outside to the memory care unit patio without staff supervision, leading to an unwitnessed fall. The resident sustained a laceration to the back of her head and required emergency department assessment. Staff and care plan reviews revealed that the need for supervision during ambulation and the resident's specific behaviors were not adequately addressed in the care plan prior to the fall. Both incidents demonstrated a lack of individualized, resident-centered interventions and supervision as required by facility policy and assessment findings. Staff interviews and record reviews indicated that known risks and behaviors were not incorporated into care plans or daily supervision practices, directly resulting in avoidable falls and injuries for both residents. The facility's failure to implement and update interventions based on each resident's assessed needs contributed to the deficiencies observed.