Failure to Prevent Fall Due to Environmental Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to identify and address environmental hazards and did not implement effective fall prevention interventions for a resident with a known history of falls. The resident, who was assessed as a high fall risk due to Alzheimer's, vascular dementia, muscle weakness, and other conditions, required assistance with activities of daily living and was supposed to use a walker for support. On the day of the incident, the resident attempted to leave the dining room table, but the space was too narrow due to the placement of another resident's large wheelchair and a water cooler. The resident's walker was not accessible, and he attempted to step over the wheelchair, resulting in a fall that caused a head injury and a C1 (neck) fracture. Multiple staff interviews confirmed that the dining room layout did not provide adequate space for safe ambulation, especially for residents with mobility aids. The resident had a documented history of previous falls, and the care plan included interventions such as ensuring the use of a walker and anticipating the resident's needs. However, the care plan had not been updated with new interventions following recent falls, and environmental hazards in the dining area were not addressed. The facility's fall prevention policy required identification and mitigation of environmental risk factors, but these measures were not effectively implemented, directly contributing to the resident's accident.