Failure to Prevent Accidents and Implement Progressive Fall Interventions
Penalty
Summary
The facility failed to ensure that areas were free from accident hazards and did not provide adequate supervision or implement progressive interventions to prevent accidents for multiple residents. For one resident with a history of stroke and significant left-sided weakness, the care plan required extensive assistance with transfers and toileting. However, a CNA was observed directing the resident to stand and transfer with only verbal cues, resulting in the resident struggling to pivot and falling heavily onto the toilet seat. The Director of Nursing was also unsure of the resident's transfer status, indicating a lack of clear communication and supervision regarding the resident's needs. Another resident with epilepsy, a history of falls, and poor safety awareness experienced at least 24 falls over a one-year period, many of which resulted in injuries such as a closed nondisplaced fracture of the right ilium, lacerations, and bruising. Despite repeated falls, there was a consistent lack of documentation of new or progressive interventions on the care plan following each incident. The resident continued to fall in various locations, including the dining room, bedroom, and smoking area, often during or after seizure activity. Staff responses were limited to immediate care and education, with no evidence of systematic changes to the care plan to address the ongoing risk. A third resident with dementia, muscle weakness, and a history of falls also experienced multiple falls in different settings, including the bathroom, dining area, and bedroom. The care plan identified the resident as at risk for falls, but after each fall, interventions were limited to verbal reminders and education about using the call light, which were repeated without modification or escalation. There was no documentation of new or progressive interventions on the care plan after repeated incidents, and the resident continued to attempt transfers and ambulation without assistance, leading to further falls and injuries.