Failure to Implement Fall Prevention Protocols and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two of four sampled residents. For one resident with dementia, the care plan identified a risk for falls and required adherence to the facility's fall protocol. However, the fall risk evaluation was incomplete and lacked a score, and after an unwitnessed fall in the hallway, the resident was assisted back to a wheelchair without assessment or physician notification. There was no documentation of the fall, no post-fall assessment, and no follow-up, despite the resident later experiencing acute hip pain and being diagnosed with a femoral neck fracture. Staff interviews confirmed the fall was not reported or documented, and the Director of Nursing acknowledged that facility protocol was not followed, resulting in delayed care and increased risk for repeat falls. For another resident admitted with a history of pulmonary embolism, the care plan also identified a fall risk and called for fall precautions. Despite this, the resident experienced two falls—one in the bathroom and another from bed. When observed, the resident's bed was not in the lowest position and a fall mat was not in place, contrary to required precautions. The facility was unable to provide documentation of fall risk precautions for this resident, and staff confirmed that fall precautions were not implemented as required, increasing the risk of injury. The facility's fall management policy required specific interventions and documentation, which were not followed in these cases.