Failure to Prevent Falls and Elopement Due to Inadequate Supervision and Hazard Control
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent repeated falls for a resident assessed as high risk for falls. The resident, who had diagnoses including diabetes, osteoporosis, osteoarthritis, and a history of traumatic fracture, experienced multiple falls during her stay. Despite being identified as high fall risk on assessments and having a history of falls, the baseline care plan did not document the resident's fall risk or specific interventions to prevent falls. After a witnessed fall and subsequent unwitnessed fall resulting in fractures of the wrist and hand, there was no documentation of new orders or interventions following the x-ray results. Additionally, after another fall where the resident was unable to stand and later became paralyzed, there was no interdisciplinary team (IDT) note or root cause analysis completed, contrary to facility policy. The facility also failed to ensure adequate supervision and safety measures for a resident assessed as high risk for elopement due to wandering behaviors. The resident, diagnosed with Lewy Bodies dementia, was able to exit the facility through an unlocked door without staff knowledge. The care plan for this resident included interventions for wandering but did not address the malfunctioning door lock, which had been reported as faulty by staff prior to the incident. The resident was found outside by a physical therapist, and there was no documentation of the elopement event in the nursing progress notes, despite an incident report being completed. Interviews with staff revealed lapses in communication and documentation regarding both residents' incidents. For the resident with repeated falls, staff did not consistently notify providers of critical results or update care plans with new interventions. For the resident who eloped, staff had previously reported the faulty door lock, and the incident was not properly documented in the clinical record. Facility policies required immediate reporting, investigation, and care plan updates for incidents and accidents, but these procedures were not followed in these cases.