Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and accident hazard prevention for a high fall risk resident, resulting in a left hip fracture, hospitalization, and surgery. The resident, an older male with multiple diagnoses including ataxia, epilepsy, gait abnormalities, schizoaffective disorder, diabetes with neuropathy, and heart failure, was assessed as having moderate cognitive impairment and was identified as high risk for falls. His care plan required supervision during transfers and ambulation, prompt response to requests for assistance, and a safe, clutter-free environment with accessible call lights and personal items. On the day of the incident, the resident was found sitting on the hallway floor after attempting to clean up spilled water, without his walker and possibly without shoes. The call light was observed out of his reach, and the room was dark. Staff interviews revealed inconsistent awareness of the resident's fall risk status and required interventions. The assigned CNA was the only one on duty for the unit, despite the usual need for two, and did not recall any special monitoring or interventions for the resident. Nursing staff did not consistently reassess the resident's pain or follow up on the x-ray order after the fall, resulting in a delay in diagnosis and transfer to the hospital. Documentation and interviews indicated that the resident was not adequately supervised, and fall prevention interventions were not reliably implemented. The resident's known behaviors, such as obsessive cleaning and not using the call light, were not sufficiently addressed through increased monitoring or environmental adjustments. The facility's fall prevention policy required individualized interventions and ongoing monitoring, but these measures were not effectively carried out for this high-risk resident, directly contributing to the incident and subsequent injury.