Failure to Provide Adequate Supervision and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a resident at high risk for falls received adequate supervision and assistive devices to prevent accidents, as required by policy. The resident, who had a history of progressive supranuclear ophthalmoplegia, repeated falls, muscle weakness, and cognitive communication deficits, experienced 21 falls over a four-month period. Despite the facility's interdisciplinary team (IDT) meeting after each fall to determine root causes and implement interventions, reviews were often delayed, and interventions were not always specific or consistently implemented. For 19 of the 21 falls, the root cause was repeatedly documented as "poor safety awareness" without further analysis to identify more precise contributing factors. Observations during the survey revealed that several care-planned interventions were not in place. The resident was found without a helmet, grip tape on the floor, or a "call don't fall" sign in the room, all of which were documented interventions. The resident's call light was found on the floor and out of reach, requiring the resident to move dangerously close to the edge of the bed to access it. Staff did not consistently notice or address the resident's proximity to fall hazards, and the resident reported that call lights were not answered in a timely manner. Additionally, there was no documentation that the medical director reviewed the resident's medications for fall risk after a significant fall, as was care-planned. Interviews with staff and the resident's representative highlighted further deficiencies in supervision and communication. The resident's representative reported long periods without staff checks and the removal of a transfer pole, which was not clearly documented or evaluated for effectiveness. Staff interviews revealed inconsistent understanding and documentation of fall risk interventions, and there was no system in place to track the completion of frequent checks. The facility lacked a specific fall committee, and floor staff were not included in daily discussions of falls and interventions, leading to gaps in communication and implementation of care plans.