Failure to Provide Adequate Supervision Resulting in Multiple Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident who experienced four unwitnessed falls within a seven-day period. The resident, who had diagnoses including hemiplegia, hemipheresis, diabetes mellitus, and Parkinson's disease, was identified as being at risk for falls upon admission. Despite this, the resident continued to fall multiple times, with each incident documented in the medical record. After the first and second falls, interventions such as keeping the bed in a low position, using side rails, bed and wheelchair alarms, floor mats, and every two-hour monitoring were implemented. However, these measures did not prevent subsequent falls. The Director of Nursing confirmed that after the second fall, the resident's family requested a sitter and for the resident to be moved closer to the nursing station, but these requests were not fulfilled due to room availability and a desire to avoid restrictive measures. The DON acknowledged that monitoring every two hours was not a sufficient intervention for this resident and that more frequent rounding and a sitter should have been provided prior to the fourth fall. The facility's own policy required staff and physicians to identify and implement pertinent interventions to prevent subsequent falls, but the lack of timely and adequate supervision contributed to the repeated incidents.