Failure to Provide Adequate Supervision and Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and immediate intervention during an incident involving two residents with cognitive impairments and behavioral disturbances. One resident, diagnosed with dementia and a history of physical aggression, physically struck another resident who was using a wheelchair. Staff statements and interviews revealed that the incident occurred when the aggressive resident believed the wheelchair belonged to them and, upon the other resident exiting the chair, struck the individual in the head before taking the chair. Multiple staff members did not witness the event directly, and the facility was unable to provide a witness statement from a hospice CNA who initially reported the incident. The care plans for both residents identified risks related to their cognitive and behavioral conditions, including the need for monitoring and supervision, but these interventions were not effectively implemented at the time of the incident. Additionally, the facility failed to implement necessary fall prevention interventions for another resident assessed as a moderate fall risk with a history of falls and left-sided weakness. Despite a completed assessment indicating the need for side rails and alarms, and the resident's consent for these devices, these interventions were not put in place. Instead, only floor mats and non-skid socks were used, which did not prevent the resident from rolling out of bed and sustaining a head injury. Staff interviews confirmed that side rails and alarms were considered appropriate and beneficial for this resident, but these measures were not included in the care plan or implemented in practice. Facility policies require that supervision and safety interventions be tailored to each resident's assessed needs and that the care team use assessment information to identify and address specific accident hazards. In both cases, the facility did not follow through with the interventions identified as necessary by assessment and care planning, resulting in preventable incidents affecting the safety and well-being of the residents involved.