Failure to Provide Adequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary safety interventions to prevent falls for a resident with a history of repeated falls, muscle weakness, and achondroplasia. The resident was dependent on staff for transfers and required the use of a high back wheelchair with fitted leg rests and a foot buddy, as documented in the care plan. However, the Kardex did not consistently include these interventions, and staff were not uniformly educated on their use. On two separate occasions, the resident was found on the floor after falling from the wheelchair, resulting in a hematoma and a facial laceration that required sutures. Documentation revealed that on one occasion, the resident was last seen approximately 20 minutes prior to the fall, and on another, about an hour prior. In both incidents, it was noted that the leg rests were not applied as indicated in the care plan, and a nurse aide admitted to not using the leg rests due to the resident's complaints of pain. Staff interviews confirmed reliance on the Kardex for care instructions, but not all staff received direct education on the required safety measures. Only eight staff members were formally educated on proper wheelchair positioning and use of leg rests, with the expectation that they would inform others. The lack of consistent documentation, incomplete staff education, and failure to follow prescribed safety interventions directly contributed to the resident's falls and resulting injuries.