Failure to Provide Adequate Supervision and Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement individualized fall prevention interventions for a resident with severe cognitive impairment and a history of recurrent falls. Despite being identified as high risk for falls and repeatedly attempting to self-transfer without assistance, the resident's care plan did not include interventions specifically addressing her poor safety awareness, severe cognitive impairment, or persistent unsafe behaviors. The interventions that were in place, such as a call bell reminder sign, anti-rollback devices, and Dycem application, were not sufficient to address the resident's needs, and re-education efforts were repeatedly used despite documentation that the resident was unable to benefit from such interventions due to her cognitive status. Progress notes documented a pattern of unwitnessed falls and self-transfer attempts over a period of several weeks, resulting in multiple injuries, including skin tears, lacerations, and ultimately a traumatic subdural hemorrhage and multiple fractures. Staff consistently noted that redirection was ineffective, and the resident continued to attempt to rise or transfer without assistance. Despite this ongoing pattern, the facility did not revise the care plan to include enhanced supervision, scheduled checks, or the use of assistive technology such as bed or chair alarms. The Director of Nursing confirmed that the facility did not provide adequate supervision or implement appropriate fall prevention interventions based on the resident's assessed needs. The failure to reassess and update the care plan in response to the resident's repeated falls and injuries resulted in significant harm, including hospitalization for serious injuries.