Failure to Supervise High-Risk Resident Resulting in Multiple Falls
Penalty
Summary
The facility failed to provide effective supervision to prevent falls for a resident with severe cognitive impairment, a history of stroke, and Alzheimer's disease. The resident, who was dependent on staff for mobility and transfers, experienced multiple falls from their wheelchair in their room. Despite being identified as high risk for falls and having care plan interventions in place, such as placing the resident in bed after meals and frequent checks, the resident continued to experience falls, including unwitnessed incidents. Documentation indicated that staff were to keep the resident in a common area or under monitoring when in the wheelchair, but these interventions were not consistently implemented. There was confusion and inconsistency among staff regarding who witnessed the resident's falls and who assisted after the incidents. Multiple staff members, including the DON, CNAs, and MDS Coordinator, provided conflicting accounts about their presence and actions during the falls. This lack of clear supervision and communication contributed to the resident's repeated falls, demonstrating a failure to ensure the area was free from accident hazards and that adequate supervision was provided.