Failure to Investigate and Prevent Repeated Falls in Cognitively Impaired Resident
Penalty
Summary
The facility failed to thoroughly investigate and address repeated falls for a resident with severe cognitive impairment, resulting in 15 falls over a three-month period, including incidents that led to a head injury and forehead laceration. The resident, who had diagnoses of dementia, psychotic disorder with delusions, and insomnia, required substantial to maximal assistance for bed mobility and transfers, and had a history of falls prior to and during admission. Despite these risk factors, the facility did not implement or document effective interventions, such as increased supervision, to prevent further falls. Multiple incident reports and progress notes detailed the resident's repeated attempts to self-transfer, get out of bed, or move without assistance, often resulting in falls. In several cases, the root cause was identified as self-transfer without staff assistance, but interventions were limited to offering the resident a chair, repositioning, or encouraging use of the call light. There was a lack of documentation regarding increased supervision, and in some instances, environmental hazards such as the call light or water cup being out of reach were not addressed. The care plan was revised multiple times, but increased supervision was not consistently included as an intervention. Interviews with facility leadership, including the DON, confirmed that despite multiple interventions, the resident continued to fall and the facility was unable to identify an effective solution. The resident was eventually moved to a dementia unit after numerous falls, but continued to experience incidents. The facility's failure to conduct thorough investigations into each fall, address environmental hazards, and implement adequate supervision contributed to the ongoing risk and occurrence of accidents for this resident.