Failure to Provide Adequate Supervision and Fall Prevention for Residents with Dementia
Penalty
Summary
The facility failed to provide adequate supervision, assistance, and meaningful interventions to prevent falls for two residents with dementia and mobility impairments. One resident experienced multiple unwitnessed falls over a period of several months, often while attempting to ambulate or transfer without assistance. Incident reports revealed that interventions were either repeated without modification, not implemented as planned, or not tailored to the root causes of the falls, such as confusion, non-compliance with call light use, and changes in room location. The care plan lacked specific strategies to ensure supervision during waking hours, and staff were not always aware of the resident's routines or needs for observation. Another resident, also with dementia and mobility issues, was observed leaving the dining room unassisted, attempting to access the restroom without staff help, and transferring unsafely from a wheelchair to a chair without locking the brakes. Staff present in the area did not provide assistance or seek help for the resident, and the unsafe transfer was not witnessed by facility staff. The resident's care plan indicated a need for staff assistance with transfers and toileting, but these interventions were not followed during the observed events. Interviews with the DON confirmed that investigations into falls did not consistently identify root causes or result in new or effective interventions. The DON was unable to provide information on how the facility would ensure adequate supervision and assistance for residents with dementia and high fall risk. The lack of meaningful, individualized interventions and failure to provide supervision and assistance directly contributed to repeated falls and unsafe situations for these residents.