Failure to Provide Adequate Supervision for High-Risk Fall Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent avoidable accidents for a resident who was identified as high risk for falls. The resident, who had multiple diagnoses including pulmonary edema, abnormalities of gait and mobility, hypertension, respiratory failure, and colon cancer, was assessed as a high fall risk upon admission. The care plan indicated the resident was at risk for falls due to altered balance, unsteady gait, and confusion, and required assistance with activities of daily living. Despite these identified risks, the resident experienced an unwitnessed fall during the night, after being last repositioned by a CNA and later found on the floor calling for help. The facility's fall risk management policies required staff to identify and implement interventions based on the resident's specific risks and causes for falling. However, the resident was not placed near the nurse station and was located in a busy hallway instead. The bed was in the lowest position, and staff reminded the resident to use the call light, but the resident was not ambulatory and required assistance. The fall resulted in the resident being sent to an acute hospital for evaluation. Documentation and interviews confirmed that the interventions in place were insufficient to prevent the fall, despite the resident's high-risk status and care plan directives.