Failure to Implement Effective Fall Prevention and Supervision
Penalty
Summary
The facility administrator failed to provide consistent administrative oversight and resources to ensure that a resident at high risk for falls received adequate supervision and individualized care planning. Despite being aware of multiple falls experienced by the resident, the administrator did not ensure that the Interdisciplinary Team implemented effective fall prevention interventions. The resident, who had diagnoses including dementia, gait abnormalities, and osteoarthritis, was assessed as moderately cognitively impaired and at high risk for falls. Staff interviews confirmed that the resident was confused, did not follow commands, attempted to get out of bed without assistance, and required supervision and continuous monitoring, which were not provided. The resident experienced a series of unwitnessed falls in his room over several months, each time being found on the floor next to his bed. Interventions such as keeping the call light within reach and encouraging its use were in place, but staff acknowledged these measures did not address the underlying causes of the falls, as the incidents occurred when the resident was unsupervised. The resident sustained injuries from these falls, including lacerations above the left eye that required emergency department visits for sutures. The resident was also on blood-thinning medication, increasing the risk of serious injury from falls. Following additional falls, the resident suffered a subdural hematoma and other head injuries, ultimately leading to hospitalization and death. The facility's policy required that fall prevention plans be reviewed and revised as appropriate, especially if a resident continued to fall. However, the administrator acknowledged that not enough fall interventions were implemented to keep the resident safe, and the necessary supervision and monitoring were not provided, resulting in repeated injuries and the resident's eventual death.