Failure to Prevent Fall in High-Risk Resident with Cognitive Impairment
Penalty
Summary
A resident with muscle weakness and severe cognitive impairment, as indicated by a BIMS score of six, was identified as being at high risk for falls, with a Fall Risk Assessment score of 17. The resident's care plan included interventions such as anticipating needs, ensuring the call light was within reach, and providing assistance as needed. However, staff interviews revealed that the resident was unable to use the call light or effectively communicate needs, making some interventions ineffective. The resident was typically supervised at the nurses station or in the Director of Staff Development's office, where staff could monitor for safety, but on the day of the incident, the resident was left alone in his room without staff presence. During this unsupervised period, the resident fell from his wheelchair, sustained a head injury, and required hospital assessment. Staff acknowledged that the resident should have been left in an area where supervision was possible, given his high fall risk and inability to call for help. The facility's fall management policy required individualized care planning and ongoing evaluation of interventions, but the implemented strategies did not adequately address the resident's specific needs, resulting in a preventable fall with injury.