Failure to Provide Supervision to Prevent Repeated Resident Falls
Penalty
Summary
Staff failed to provide adequate supervision to prevent repeated falls for a resident with a known history of attempting to go to the bathroom independently during early morning hours. The resident experienced multiple falls between 3:00 a.m. and 5:00 a.m., as documented in several progress notes, with incidents resulting in injuries including a head laceration and, ultimately, a left hip fracture that required surgical intervention. The facility's fall management policy required staff to identify and implement interventions based on the resident's specific risks, but this was not effectively carried out. Despite the resident's power of attorney (POA) repeatedly notifying staff and requesting that the resident be checked during the high-risk time frame, this information was not formally communicated to management or incorporated into the resident's care plan. The LPN who received the POA's request did not ensure the intervention was relayed to the night shift or documented for agency staff, resulting in a lack of targeted supervision during the times when the resident was most at risk for falls.