Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure staff familiarity with a resident assessed as high risk for falls. The resident, who had severe cognitive impairment and was dependent on staff for most activities of daily living, experienced multiple falls, including an unwitnessed fall that resulted in hospitalization for head trauma. The facility's care plan and interdisciplinary team (IDT) interventions specified that the resident should not be left unattended in a wheelchair, and that staff should escort or endorse the resident between locations. However, these interventions were not consistently implemented, particularly after the resident was moved to a new room with unfamiliar caregivers. Observations and interviews revealed that staff were not always aware of or adhering to the resident's fall prevention interventions. On one occasion, the resident was found unsupervised in the hallway after wheeling himself from the activity room, contrary to the care plan. Staff interviews indicated that communication between activity and nursing staff was primarily verbal and not documented, leading to lapses in supervision. Additionally, there were no visible indicators in the resident's environment to alert staff to the high fall risk, and staff monitoring intervals may not have been sufficient given the resident's condition. The facility's policies required that interventions be communicated to all relevant staff, implemented consistently, and re-evaluated after each fall. Despite these requirements, the resident continued to experience falls, including in situations where new caregivers were unaware of the resident's routine. The lack of consistent supervision, inadequate communication, and failure to reassess and adjust interventions after each fall directly contributed to the resident's repeated falls and subsequent injury.