Failure to Provide Adequate Fall Prevention and Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that fall interventions and adequate supervision were in place for multiple residents identified as high risk for falls. Several residents, all with significant medical histories including dementia, unsteady gait, and previous falls, experienced unwitnessed or inadequately supervised falls that resulted in serious injuries such as femoral fractures, vertebral fractures, and lacerations. In multiple instances, residents were found on the floor by staff after the fact, and documentation revealed that required interventions, such as ensuring call lights were within reach, were not consistently implemented. For example, one resident was found on the floor with a laceration and a fractured right femur after attempting to ambulate unsupervised, with staff later confirming that the call light was not accessible and that the resident was known to walk independently despite being high risk. Interviews with staff and review of records indicated that high-risk residents were often left unsupervised or allowed to ambulate alone, despite care plans and assessments indicating the need for supervision. Staff statements confirmed that some residents, due to cognitive impairment and poor safety awareness, would attempt to walk or toilet themselves without assistance, and that supervision was not always provided. In several cases, staff were not present or were engaged in other tasks when falls occurred, and some staff were unclear about the specific supervision needs of the residents in their care. Additionally, the facility lacked a clear policy on resident supervision, and staff relied on informal communication or personal knowledge rather than standardized protocols. Documentation further showed inconsistencies in incident reporting and care plan implementation. For example, one resident's fall with injury was not accurately documented in the injury report, and another resident's care plan interventions, such as purposeful rounding and environmental safety measures, were not reliably followed. The facility's own records indicated a pattern of repeated falls among high-risk residents, with multiple incidents occurring over a short period. Despite the presence of care plans and fall risk assessments, the necessary interventions and supervision were not consistently provided, directly leading to multiple residents sustaining serious injuries.