Failure to Provide Adequate Supervision and Safe Environment for High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment and provide adequate supervision to prevent multiple falls for a resident with a significant history of falls and cognitive impairment. The resident, who had previously been hospitalized for multiple falls following a craniotomy, continued to experience frequent unwitnessed and witnessed falls after admission to the facility. Despite the implementation of various care plan interventions such as reminders to use the call light, placement of signs, medication reviews, and environmental adjustments, the resident sustained 14 falls over several months. Many of these falls were unwitnessed, and the interventions did not include increased supervision or frequent checks, even though the resident was known to be non-compliant with safety reminders and had memory deficits. Observations revealed that the resident was housed in a room located at the far end of the hallway, away from the nurses' station and staff visibility, and was often left unsupervised. The resident did not participate in therapy sessions, group activities, or supervised outdoor time, and typically remained in the room with a roommate. Environmental hazards, such as a broken fan on the floor, were present in the resident's room for several days and were not removed despite being identified as a tripping hazard. Additionally, safety equipment such as fall mats and side rails were not consistently in use, and required signage was missing from the room. Interviews with staff confirmed awareness of the resident's frequent falls and cognitive challenges, but no interventions to increase supervision were implemented until after the survey observations. Staff acknowledged that the resident was not listed for frequent checks and that the room location was not optimal for monitoring. The DON confirmed that interventions had not been effective in preventing falls and that incident reporting for the resident's falls had ceased. The lack of increased supervision and failure to address environmental hazards contributed to the ongoing risk and occurrence of falls for the resident.