Failure to Provide Adequate Supervision and Fall Prevention for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent falls for two residents with known cognitive impairments, poor safety awareness, and histories of impulsive behaviors and multiple falls. For one resident, staff were aware of his moderate cognitive impairment, unsteady gait, and repeated incidents of getting out of bed without assistance, yet did not provide the necessary supervision or one-on-one monitoring. Despite multiple unwitnessed falls occurring in his room, interventions remained limited to reminders to use the call light and environmental adjustments, which staff acknowledged were ineffective due to the resident's inability to remember or comply. This resident experienced several unwitnessed falls resulting in injuries, including lacerations requiring emergency care and ultimately a fatal subdural hematoma following repeated falls. Another resident, also with moderate cognitive impairment and a history of brain injury, muscle weakness, and poor balance, was assessed as a fall risk but did not have a fall prevention care plan or interventions in place prior to his first fall. The resident exhibited impulsive behaviors, such as standing up suddenly and attempting to ambulate without assistance, leading to eight falls within a 30-day period. Staff interviews confirmed that the resident required constant supervision to prevent falls, but interventions were limited to periodic checks and environmental cues, which did not prevent further incidents. Documentation showed that care plans and interventions were not consistently updated or implemented in response to the resident's escalating fall risk and repeated incidents. Facility policies reviewed indicated that individualized, resident-centered fall prevention plans should be developed and revised as needed, and that residents identified as high risk should not be left unsupervised while out of bed. However, the facility did not follow these protocols, as evidenced by the lack of effective supervision and failure to implement or update care plans in response to ongoing falls. Staff and administration acknowledged that the interventions in place were insufficient to address the residents' needs and prevent avoidable accidents, resulting in repeated injuries and, in one case, death.