Failure to Follow Fall Prevention Care Plan and Provide Adequate Supervision
Penalty
Summary
The facility failed to follow the established plan of care and provide adequate supervision for a resident identified as being at risk for falls and accident hazards. According to the resident's care plan, staff were required to always remain in front of the resident during showers and maintain line-of-sight supervision at all times, without leaving the resident unattended. On the day of the incident, a CNA briefly turned away from the resident in the shower room to place lotion on the counter, leaving the resident in their wheelchair on a sloped section of the floor. During this short interval, the resident, who was known to exhibit rocking and agitated behaviors, tipped over and fell to the floor. The investigation revealed that the wheelchair's placement on the curved, sloped floor contributed to the fall, and staff did not adhere to the care plan's supervision requirements. Further review showed that after the fall, the resident was found back in their wheelchair and appeared stable upon initial RN assessment. Interviews with staff confirmed that the expectation was for staff to remain with the resident at all times, especially for those on one-on-one supervision due to behavioral risks and mobility. The facility's fall protocol also required that a nurse assess any resident who had fallen before they were moved, which was not followed in this case. Staff and administrative interviews acknowledged that the care plan was not followed and that the environmental hazard of the sloped shower room floor was a contributing factor to the incident.