Failure to Implement Fall Risk Care Plan and Provide Adequate Supervision
Penalty
Summary
The facility failed to implement the fall risk care plan for one resident by not providing frequent visual monitoring as required. The resident, who had a history of necrotizing fasciitis, generalized muscle weakness, lower leg osteomyelitis, and chronic ulcers on both feet, was admitted with significant mobility impairments and required supervision and assistance with activities of daily living. The care plan specifically called for frequent visual checks to prevent falls, but during observation, the resident was found with curtains drawn around the bed, making visual monitoring difficult, and was not wearing non-slip socks. The resident reported always having the curtains drawn, further impeding staff's ability to monitor her. A review of records revealed that the resident was taking multiple medications, including anticoagulants and antihypertensives, and was assessed as unable to self-transfer. Despite these risk factors, staff interviews confirmed that frequent visual monitoring was not being performed. The resident experienced a fall during the night and self-reported getting back up without injury. The facility's Fall Risk Assessment was found to be inaccurate, and the Interim Director of Nursing acknowledged the importance of following the care plan for frequent monitoring, emphasizing that it is the responsibility of all staff to ensure the resident's safety. The facility's policy required adequate supervision to prevent accidents, which was not followed in this case.