Failure to Provide Adequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for two residents, resulting in deficiencies related to accident hazards and fall prevention. One resident, who had multiple diagnoses including a recent hip fracture, required transfers with a mechanical lift and two staff members as per physician orders and care plan. However, during a transfer, only one CNA was present, and the resident's feet were not properly positioned on the sit-to-stand lift, causing the resident to be lowered to the floor. This incident was confirmed through interviews and documentation, which verified that the required two-person assistance was not provided during the transfer. Another resident, with a history of Parkinson's disease, repeated falls, and severe cognitive impairment, experienced multiple falls over a period of several months. The care plan and physician orders included interventions such as nonskid socks, a body pillow, and a floor mat to reduce fall risk. Despite these interventions, documentation revealed that fall interventions were not consistently in place, and several falls occurred when required equipment was either not ordered or not documented as being used. Additionally, post-fall investigations were incomplete, lacking thorough root cause analyses as required by facility policy. Many investigation forms were missing critical information about the circumstances of the falls, interventions in place at the time, and environmental factors. Interviews with nursing staff and review of facility records confirmed that fall investigations for this resident were not fully completed and that interventions were not always implemented or documented as required. The facility's own fall protocol policy mandates timely identification of causes and implementation of interventions, but this was not consistently followed. The lack of adequate supervision, incomplete documentation, and failure to ensure fall prevention measures were in place contributed to repeated falls and the identified deficiencies.