Failure to Provide Adequate Supervision Resulting in Resident Falls
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including moderate cognitive impairment, osteoporosis, and dementia, was not provided with adequate supervision to prevent falls. The resident had a documented history of falls, impaired mobility, and required assistance with activities of daily living (ADLs) and transfers. Despite these needs, the care plan interventions prior to the falls primarily included having the call light within reach, staff assistance for transfers and toileting, and the use of non-slip socks or shoes during mobility. However, the resident experienced two falls within a short period, one in the bathroom while attempting to transfer from the wheelchair without assistance and another after falling asleep in the wheelchair and sliding to the floor. Documentation and staff interviews revealed that the resident had reported using the call light for assistance but experienced significant delays in staff response, sometimes waiting an hour or more. The resident stated that due to these delays, he attempted to perform tasks independently, leading to falls. Staff interviews indicated inconsistent awareness of the resident's fall risk status and interventions, with one CNA unaware that the resident was a fall risk prior to the incidents and noting the absence of a yellow armband, which was supposed to indicate fall risk. The care plan and interventions were not consistently communicated or implemented among staff, and there was a lack of timely and effective supervision tailored to the resident's needs. The facility's policy required providing an environment free from accident hazards and adequate supervision to prevent avoidable accidents. Despite this, the resident's increased weakness, cognitive impairment, and history of falls were not sufficiently addressed through effective supervision or timely staff response. The lack of prompt assistance and inconsistent implementation of fall prevention interventions contributed to the resident's repeated falls and subsequent injuries, including compression fractures and increased back pain.