Failure to Prevent Repeated Falls and Injuries Due to Ineffective Supervision and Intervention
Penalty
Summary
The facility failed to provide effective monitoring, supervision, and implementation of interventions to prevent repeated falls and injuries for multiple residents. For one resident with severe cognitive impairment and a history of falls, there were at least 15 documented falls, some resulting in serious injuries such as a dislocated hip, femur fracture, and back fracture. The facility did not consistently review or revise care plan interventions after each fall, and there were omissions in required neurological checks and documentation. Staff education on fall prevention was not always documented, and some falls were not included in the facility’s incident log. Another resident with dementia, impaired vision, and a history of frequent falls experienced 36 falls over a period of time, resulting in various injuries including abrasions, contusions, lacerations, and head injuries, with several hospital transfers. The care plan interventions remained largely unchanged despite repeated falls, and the facility continued to rely on ineffective strategies such as reminders to use the call light, even though the resident was impulsive and forgetful. There was no evidence that the facility evaluated the reasons for failed interventions or increased supervision, and staff interviews confirmed that increased monitoring was not attempted despite ongoing falls. A third resident, dependent on staff for transfers due to left-sided weakness from a stroke, fell while left unattended on the toilet, resulting in a fracture to the eye socket and left lower leg. The care plan had instructed staff to stay with the resident during toileting, but this intervention was not followed. The facility’s investigation acknowledged that staff left the resident unattended despite existing care plan instructions. Across these cases, the facility failed to assess, evaluate, and implement effective interventions to prevent repeated falls and injuries, and did not ensure that staff consistently followed care plan instructions or documented required assessments.
Removal Plan
- Placed both Resident 19 and 50 on one to one (1:1) supervision.
- Educated all staff to the policies and procedures for accident prevention and fall interventions, including notification to management of ineffective fall interventions.
- Reviewed accidents to ensure care planned interventions were resident specific.
- Reviewed Resident 19 and 50's care plans and ensured interventions were pertinent to the root-cause of the falls.