Failure to Implement and Monitor Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of person-centered fall interventions for a resident with dementia and a high risk for falls. The resident, who had severe cognitive impairment, muscle weakness, abnormal mobility, confusion, and a history of falls, was admitted for long-term care and required maximal assistance with toileting and moderate assistance with transfers. Despite being identified as a high fall risk, the resident was observed multiple times without appropriate supervision and was not consistently provided with required non-skid footwear as outlined in her care plan. On one occasion, the resident was found on the floor in her room with a head injury, having sustained a traumatic brain injury and subdural hematomas after an unwitnessed fall. The facility's investigation revealed that the last staff check on the resident was nearly an hour before the fall, and the resident was attempting to go to the bathroom unassisted. Observations during the survey also showed periods when no staff were present in the secured unit, and staff left the unit unattended, leaving the resident and others unsupervised. Additionally, staff were seen not actively monitoring the resident, with some engaged in personal activities such as using cell phones. The care plan for the resident included interventions such as providing hands-on assistance for standing and sitting, ensuring the use of non-skid footwear, and anticipating and meeting the resident's needs. However, these interventions were not consistently implemented, as evidenced by the resident ambulating alone in the hallway, wearing inappropriate footwear, and being left unsupervised. Staff interviews confirmed a lack of awareness and training regarding additional fall prevention interventions, and the facility's own policy required systematic monitoring and modification of interventions, which was not followed.