Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when a facility failed to provide adequate supervision and implement effective fall prevention interventions for a resident assessed as high risk for falls. The resident, who had diagnoses including osteoporosis, type 2 diabetes, dementia, gait abnormalities, and muscle weakness, was severely cognitively impaired and required supervision while ambulating. Despite being identified as high risk through multiple fall risk assessments and care plans, the resident experienced three unwitnessed falls within a two-week period. The facility's care plans and fall prevention program, including the Red Sneaker Program, outlined interventions such as supervision, environmental safety checks, and regular monitoring. However, the resident was placed on Level 2 supervision, which involved staff checking every 15 minutes, rather than direct in-room supervision, even after repeated falls. The care plans included interventions like assessing dizziness, monitoring for injury, and providing education, but staff acknowledged that the resident's dementia prevented retention of safety education or reminders. Interviews and record reviews revealed that the interdisciplinary team (IDT) did not increase the level of supervision to direct, in-room monitoring until after the third fall. The Director of Nursing confirmed that Level 2 supervision was not effective for this resident, as evidenced by the repeated falls. The facility's own policies required individualized, resident-centered interventions and modification of interventions if falls recurred, but these were not implemented in a timely manner for this resident.