Failure to Provide Adequate Supervision and Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement and follow progressive interventions and provide appropriate supervision to prevent falls for a resident with severe cognitive impairment and a high risk for falls. The resident, who had diagnoses including metabolic encephalopathy and required partial to moderate assistance with mobility and transfers, experienced multiple falls. Despite being identified as high risk and having a care plan that included interventions such as prompting or assisting with position changes, toileting, and encouraging the use of the call light, the resident attempted to self-transfer to the bathroom and fell, sustaining a head injury. The care plan also included education for the resident to use the call light and wait for staff assistance, but the resident's severe cognitive impairment limited the effectiveness of this intervention. Following the initial fall, the resident was found on the floor again after attempting to get up independently, which resulted in a fracture of the left inferior pubic ramus. Documentation shows that the resident was not always toileted prior to being put to bed, and staff interviews indicated that the resident could stand but required significant assistance. The facility's policy emphasized the need to identify residents at risk for falls and to implement preventative strategies, but the failure to provide adequate supervision and timely assistance contributed to the resident's repeated falls and subsequent injury.