Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and accident prevention for a resident with a known history of falls, severe cognitive impairment, and multiple diagnoses including dementia, schizophrenia, anxiety disorder, and major depressive disorder. The resident was assessed as a fall risk and had a care plan that included interventions such as ensuring the use of non-skid footwear, frequent rounding, and supervision during mobility and transfers. Despite these documented interventions, the resident experienced multiple falls, including an unwitnessed fall that resulted in a laceration to the left eyebrow requiring sutures and hospitalization. Direct observations and interviews revealed that the resident was often found without non-skid footwear, and staff acknowledged that the resident frequently removed the socks intended to prevent falls. The resident's call light was not consistently accessible or understood by the resident, who was severely cognitively impaired and unable to reliably request assistance. Staff interviews indicated that supervision was not constant, with staff present at the nurse's station only 'most of the time,' and monitoring was often limited to visual checks from a distance. The resident's care plan interventions, such as supervision and use of non-skid footwear, were not consistently implemented or maintained. Documentation and staff statements also indicated that fall risk assessments were not always completed accurately, and there was a lack of individualized or enhanced supervision for this high-risk, impulsive resident. The facility's fall prevention policy required ongoing assessment and implementation of safety interventions, but these measures were not effectively carried out for this resident, resulting in a preventable injury. The deficiency was further supported by the facility's own policies and staff acknowledgments that interventions were not always in place or effective.