Failure to Prevent Falls and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and accident hazard prevention for two residents reviewed for falls. One resident, admitted with pulmonary heart disease and chronic diastolic heart failure and receiving hospice services, experienced five unwitnessed falls within a little over a month. Three of these falls occurred during self-toileting attempts, and interventions such as a toileting plan, fall mat, and bed in the lowest position were inconsistently documented between the care plan and the Kardex. The resident's care plan did not reflect all interventions implemented, and there was a lack of thorough root cause analysis after each fall. The final fall resulted in a displaced left femoral neck fracture, and the fall mat was not in place at the time. Additionally, the resident was not assessed by an RN before being moved after the fall. Another resident, admitted with parkinsonism and a history of falls, fell forward from a wheelchair and sustained a head injury requiring sutures. At the time of the incident, the resident was being transported by staff without wheelchair foot pedals in place, despite requiring staff assistance for mobility and not propelling the wheelchair independently. The care plan was updated to include the use of foot pedals for out-of-facility appointments only after the fall occurred. Staff interviews confirmed that the pedals were not applied at the time of the fall, and the incident happened quickly as the resident was being wheeled out of the room. In both cases, the facility's failure to implement and document individualized interventions, ensure consistent communication between care plans and task lists, and provide adequate supervision directly contributed to the residents' falls and injuries. The lack of thorough investigation and timely updates to care plans following each incident further contributed to the deficiencies identified by surveyors.