Failure to Follow Fall Management Policies and Provide Adequate Supervision
Penalty
Summary
The facility failed to follow its own policies and procedures regarding fall prevention and management for two residents, resulting in deficiencies related to accident hazards and inadequate supervision. For one resident with Alzheimer's disease and severe cognitive impairment, the care plan required that the resident not be left unattended during toileting. However, a CNA left the resident alone in the restroom with the door closed for privacy, contrary to the care plan. This lack of supervision led to an unwitnessed fall, resulting in a laceration to the right brow bone, abrasions, and the need for transfer to an acute care hospital for further treatment, including sutures. The facility also failed to update the resident's fall risk assessment after the incident and did not document all interventions recommended by the interdisciplinary team (IDT) following the fall. In the case of another resident with a history of sepsis, diabetes with neuropathy, and muscle weakness, the facility did not ensure that an IDT meeting was conducted after the resident sustained a fall and was readmitted to the facility. The resident was assessed as high risk for falls, and the care plan included frequent safety monitoring and fall risk precautions. Despite this, there was no documentation of an IDT meeting or review of the fall, as required by the facility's fall management policies. The absence of this review meant that the circumstances of the fall and the effectiveness of the care plan interventions were not evaluated by the IDT. Both cases demonstrate that the facility did not adhere to its established fall management programs, which require timely updates to care plans, post-fall assessments, and IDT reviews after falls. The failure to implement and document these interventions and reviews resulted in residents being left at risk for further accidents and injuries, as evidenced by the unwitnessed fall and subsequent injury in one resident and the lack of post-fall IDT review in another.