Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement effective fall prevention interventions for a resident with a significant history of falls and multiple risk factors, including severe cognitive impairment, Parkinson's disease, Alzheimer's disease, schizophrenia, and repeated falls. Despite the resident experiencing several falls over a period of months, the facility did not consistently identify or address all contributing factors for each incident. For example, after falls where the resident was found without non-skid socks or attempting to self-transfer, the care plan was not updated to address these specific issues, and interventions such as non-slip material for the wheelchair or enhanced supervision were not considered or implemented. The facility's fall investigations were incomplete, with the Assistant Director of Nursing (ADON) acknowledging that details from interviews and investigations were not documented. In several instances, the interventions added to the care plan were not directly related to the identified causes of the falls. For example, after a fall related to the resident attempting to retrieve dentures, the only intervention was a dental evaluation, which the Medical Director stated would not prevent falls. Similarly, after a fall where the resident slid out of a wheelchair while changing clothes and was found wearing plain socks instead of non-skid socks, the only intervention was to assist with changing clothes, with no action taken regarding the lack of non-skid socks or the use of non-slip material in the wheelchair. Additionally, the facility failed to ensure safe transfer practices following a fall. After one incident, staff manually lifted the resident from the floor to the bed by lifting under the arms, despite the resident being unable to bear weight, which is contrary to safe transfer protocols and increased the risk of injury. The facility did not identify or address this improper transfer method during their investigation. The lack of comprehensive fall investigations, failure to update care plans with appropriate and individualized interventions, and inadequate supervision contributed to repeated falls and, in one case, resulted in a significant injury (right humeral neck fracture) for the resident.