Failure to Implement Fall Prevention Interventions and Provide Adequate Supervision
Penalty
Summary
The facility failed to implement care-planned interventions and provide adequate supervision to prevent accidents for two residents with a history of falls. One resident, who had severe cognitive impairment and was assessed as a fall risk due to unsteady gait and poor balance, had a care plan intervention requiring dycem on the wheelchair seat and pressure alarm to prevent sliding. However, on the night of the incident, the dycem was not in place, and the resident fell from the wheelchair, sustaining a skin tear. Staff documentation confirmed the absence of the dycem at the time of the fall, and facility leadership could not provide further documentation regarding the missing intervention. Another resident, also identified as a high fall risk with a recent history of multiple falls, intermittent confusion, and decreased balance, experienced a fall while ambulating in the hallway with a nurse aide. The resident lost consciousness briefly after hitting her head during the fall and was transported to the hospital. Clinical records and therapy notes indicated that the resident required supervision or contact guard assistance for ambulation and needed frequent verbal cues for safety. Despite these documented needs, the resident's care plan did not specify the required level of ambulation assistance, and the nurse aide was walking ahead of the resident rather than providing close supervision at the time of the fall. The facility's failure to follow care-planned interventions for fall prevention and to provide adequate supervision for residents at high risk for falls resulted in preventable accidents. Documentation and interviews confirmed that the necessary interventions and supervision were not consistently implemented for these residents, directly contributing to their falls and injuries.