Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement effective fall interventions for two residents with a history of falls and significant cognitive and physical impairments. One male resident with vascular dementia, poor safety awareness, and impaired mobility experienced multiple unwitnessed falls in various locations, including his room, lounge, dining room, and hallway. Despite a care plan with numerous interventions such as keeping the bed in the lowest position, frequent observation, and positioning near the nursing station, the resident continued to fall while attempting to transfer or retrieve items independently. Observations revealed that his call light was not accessible, and he was often left unsupervised, leading to repeated incidents. A female resident with epilepsy, stroke, gait abnormalities, and a history of falls also experienced several unwitnessed falls in her room. Her care plan included interventions like ensuring the call light was within reach, encouraging the use of appropriate footwear, and providing prompt assistance. However, she was observed alone, attempting to dress herself and ambulate without assistance, despite being known to resist care and having cognitive deficits. The resident repeatedly fell while trying to perform activities of daily living independently, such as dressing or reaching for items, and often refused to use the call light or accept help from staff. Interviews with facility staff, including the restorative nurse and DON, confirmed that the facility does not provide one-on-one monitoring, does not use restraints or fall alarms, and relies on staff to check on residents periodically. Staff acknowledged the residents' impulsivity, confusion, and lack of safety awareness but indicated that falls "just happen" and that interventions are modified as needed. Despite multiple falls with similar causes, effective supervision and interventions to prevent recurrence were not consistently implemented, resulting in ongoing unwitnessed falls for both residents.