Failure to Provide Adequate Supervision and Timely Interventions for Fall Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and timely interventions to prevent accidents for a resident with a high risk of falls. The resident, who had diagnoses including dementia, a history of falls, gait abnormalities, weakness, and insomnia, was admitted with significant cognitive impairment and required partial to moderate assistance with activities of daily living. Despite a physician's recommendation for a physical therapy (PT) evaluation and a transition to a walker without wheels for safety, the resident continued to use a four-wheel walker, and the PT evaluation was not conducted until nearly two weeks later. Within a short period, the resident experienced three unwitnessed falls, all occurring in the early morning hours when she got out of bed independently. Two of these falls resulted in injuries, including facial bruising and a head laceration requiring hospital treatment and stitches. The facility did not identify a pattern in the timing or circumstances of the falls, nor did they implement targeted interventions to address the repeated early morning incidents. Additionally, the resident's medical records indicated that she developed high blood pressure and a urinary tract infection (UTI) during this period, both of which increased her risk for falls, but these factors were not promptly identified or addressed in the fall prevention plan. The facility's fall protocol required staff to investigate causes of falls within 24 hours and to monitor and adjust interventions as needed. However, the resident's care plan and post-fall investigations did not reflect timely or effective changes in response to the repeated incidents. The resident continued to use unsafe equipment, was not provided with recommended therapy services in a timely manner, and did not receive increased supervision or specific interventions during the high-risk early morning hours. Staff interviews confirmed gaps in communication, delayed implementation of interventions, and a lack of recognition of the fall pattern.