Failure to Prevent Accidents Due to Inadequate Supervision and Implementation of Fall Interventions
Penalty
Summary
The facility failed to ensure that three residents received adequate supervision and that their environment was free from accident hazards, resulting in preventable accidents. One resident, admitted with a history of a recent hip fracture due to a fall at home and severe cognitive impairment, was incorrectly assessed as low fall risk upon admission. Despite a care plan that included keeping items within reach and assisting with transfers, the resident was left unattended on a bedside commode for over 25 minutes after activating the call light. The resident attempted to retrieve toilet wipes that were not within reach, resulting in a fall that caused a right wrist and right hip fracture, requiring hospitalization. The interventions for supervision during toileting and the use of a reacher device were only implemented after the fall occurred. Another resident, with diagnoses including dementia, muscle weakness, and a history of falls, was identified as high risk for falls. Observations revealed that required fall prevention interventions, such as the use of a tactile wedge pillow to provide bed boundaries, were not consistently implemented. The resident experienced multiple unwitnessed falls, and staff interviews confirmed a lack of awareness and inconsistent use of the prescribed interventions. Documentation showed that the resident was found on the floor on more than one occasion without the tactile pillow in place, despite it being part of the care plan. A third resident, also with dementia and a history of frequent falls, was observed being transported in a wheelchair without foot pedals attached, requiring the resident to hold her legs and feet up off the ground. This occurred multiple times, and staff did not intervene to ensure the resident's safety during transport. The care plan did not include an intervention to ensure foot pedals were in place during staff-assisted transport, and staff interviews revealed uncertainty about best practices for wheelchair foot pedal use. These failures demonstrate that the facility did not consistently implement or communicate individualized fall prevention interventions as required by their own policies.