Failure to Provide Adequate Supervision and Follow Fall Policy
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and follow its fall prevention policy for one resident with paraplegia, PTSD, conversion disorder with seizures, depression, UTI, and osteoporosis. The resident, who is cognitively intact and requires maximal assistance for transfers and toileting, reported that after a medical procedure, she was in pain and felt weak. She activated her call light to request assistance to use the bathroom, but no staff responded for an extended period. As a result, she attempted to go to the bathroom independently, became weak, and fell in the bathroom. She then crawled to her wheelchair and pushed it into the hallway to get staff attention. The facility's fall report log did not document this incident, and no fall risk management assessment was initiated until prompted by the surveyor. The agency LPN and other staff believed the resident's behavior of placing herself on the floor was typical, but there was no documentation or care plan evidence to support this claim. The facility's fall prevention policy requires that all falls be reviewed and a fall risk evaluation be completed, which was not done in this case. The DON confirmed that the expected procedure following a fall was not followed, and there was a lack of documentation regarding the resident's alleged behaviors.