Failure to Provide Adequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision and implement fall prevention interventions for two residents identified as high risk for falls. One resident, with a history of polyneuropathy, generalized muscle weakness, cognitive deficits related to Parkinson's, and requiring extensive assistance with bed mobility, was left unattended in bed by a CNA who walked away to obtain supplies during care. This resulted in the resident rolling out of bed and sustaining a right eyelid injury. The resident's care plan specified that they should never be left in an unsafe or uncomfortable position, and assessments documented the need for extensive assistance for all bed-related activities. Another resident, also identified as high risk for falls due to spinal stenosis, generalized edema, muscle weakness, poor safety awareness, and a history of falls, experienced multiple falls. The care plan required frequent checks and assistance with bathroom needs. On one occasion, the resident attempted to get up alone after waiting an extended period for staff to respond to a call light, resulting in a fall to her knees. The resident reported frequent long waits for assistance, especially at night, sometimes resulting in accidents. On another occasion, the resident fell while trying to use the bathroom, and investigation revealed that staff did not follow the care plan intervention for frequent checks. Interviews with the Director of Nursing confirmed that in both cases, staff failed to provide the required supervision and did not adhere to individualized care plan interventions. The facility's Fall Reduction Program policy required individualized interventions and supervision based on assessed risks, but these were not consistently implemented, leading to preventable falls and injuries.