Failure to Implement Adequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to implement appropriate interventions and provide adequate supervision to prevent falls for two residents with a history of multiple falls and fall-related injuries. One resident, with severe dementia, generalized muscle weakness, and repeated falls, experienced several incidents where she was found on the floor, including a witnessed fall resulting in a nasal and rib fracture. During this incident, the resident was being transported in a wheelchair without footrests, as requested by her son, and her feet became entangled, leading to the fall. The care plan did not address the absence of footrests, and there was no documentation of interventions for safe transport. The resident also had episodes of agitation and purposely sliding out of her chair, but the care plan lacked interventions for increased supervision during these behaviors. Another resident, with moderate cognitive impairment, debility, and a history of falls, was dependent on staff for mobility and had multiple falls within a short period. Despite being identified as a high fall risk and having care plan interventions such as fall mats and a scoop mattress, the resident was repeatedly found on the floor, sometimes without the prescribed fall mats in place. The resident was unable to consistently use the call light and often attempted to get out of bed or walk unassisted, resulting in injuries such as skin tears and bruising. Observations revealed inconsistencies in the implementation of care plan interventions, such as the absence of fall mats when required. Staff interviews and record reviews indicated that supervision was not consistently provided, and care plan interventions were not always updated or followed according to the residents' changing needs and behaviors. There was a lack of documentation regarding the rationale for certain interventions, such as the removal of footrests, and insufficient evidence of staff statements or thorough investigation following falls. The facility did not ensure that the environment was free from accident hazards or that adequate supervision was provided to prevent accidents for residents at high risk of falls.