Failure to Assess, Care Plan, and Supervise High Fall Risk Resident
Penalty
Summary
The facility failed to accurately assess and evaluate a resident who was at high risk for falls, and did not provide an appropriate plan of care or implement fall prevention interventions. Despite the resident's history of repeated falls, traumatic subdural hemorrhage, and a coagulation defect, the facility did not include any fall prevention interventions in the care plan upon admission or readmission. The fall risk assessments were incorrectly scored, indicating the resident was not at high risk, even though the actual scores were well above the threshold for high risk. No baseline care plan interventions were provided, and the care plan for falls was only created after the resident experienced a fall. The resident experienced two unwitnessed falls while in the facility. The first fall resulted in an epidural brain bleed and required hospital admission, while the second fall caused a laceration to the back of the head, also necessitating hospital transfer. Staff interviews revealed that the resident was left alone in the room during times when assistance was needed, and staff were unsure if alternative supervision or transfer to a wheelchair would have prevented the falls. The resident was not included on the 'get up' list, and staff cited being too busy to provide additional supervision or assistance during critical times. Further review of the facility's investigation process showed that staff whereabouts at the time of the falls were not accounted for, and written statements from assigned CNAs were missing. The facility's fall prevention policy required fall risk evaluations on admission, readmission, quarterly, and after each fall, with care plans to be updated accordingly. However, these procedures were not followed, and the lack of timely assessment and intervention contributed to the resident's repeated falls and injuries.