Failure to Provide Adequate Supervision and Post-Fall Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate interventions to prevent falls for three residents with known fall risks. For one resident with dementia and muscle weakness, multiple falls occurred, including incidents where the resident attempted to transfer without assistance and sustained injuries such as a bruised elbow and a laceration above the eyebrow. Documentation revealed that post-fall assessments and neuro checks were inconsistently completed, with missing times for monitoring and lack of new neuro checks after subsequent falls. The Interdisciplinary Team (IDT) did not review fall events promptly, and care plan interventions were either vague or not updated to address the specific circumstances of each fall. Another resident with a history of cerebral infarction, muscle weakness, and lack of coordination experienced a witnessed fall after rolling out of bed while drowsy. The post-fall evaluation noted poor lighting as an environmental factor and documented a significant bruise. However, the IDT post-fall review was delayed by several days, and the care plan interventions were not clearly documented or tailored to the resident's needs at the time of the fall. There was also confusion in the documentation regarding whether the fall was witnessed or unwitnessed, and staff education provided as an intervention was not recorded in the medical record. A third resident with Huntington’s disease, dementia, and a history of falls was found on the bathroom floor with abrasions and redness after an unwitnessed fall. The post-fall evaluation and IDT review contained discrepancies in the timing of the fall, and no new interventions were added to the care plan following the incident. The recommended medication regimen review was not documented as completed, and there was no evidence that neuro checks were performed as required. These deficiencies demonstrate a lack of timely assessment, documentation, and individualized intervention following fall events, contrary to the facility’s own policies for accident prevention and supervision.