Failure to Provide Adequate Supervision and Progressive Fall Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement progressive interventions to prevent accidents and falls for three residents with known risk factors. One resident with chronic kidney disease, COPD, and mild dementia, who was assessed as moderately cognitively impaired and required supervision during showering, experienced a fall in the shower room while unsupervised. The resident reported that an aide had stepped out of the room prior to the fall, and the administrator confirmed that staff were not present at the time, despite the expectation that supervision should have been provided for showering. Another resident with dementia, anxiety, depression, and hypertension was found to have a large bruise on her right forearm, with no clear documentation or interventions in place to prevent further bruising. Staff interviews revealed that the resident was confused, restless, and frequently hit her arms against her wheelchair, but there was no evidence of interventions such as padding the wheelchair arms. The Director of Nursing acknowledged the lack of clear documentation and appropriate interventions following the incident, and the facility was unable to provide an accident/incident policy when requested. A third resident with dementia, major depressive disorder, and multiple physical impairments experienced multiple falls over several months. Despite a care plan noting the need for monitoring and intervention, there was no documentation of new or progressive interventions following each fall, as required by facility policy. The resident continued to fall while attempting to self-transfer or move without assistance, and staff interviews confirmed that new interventions were not consistently implemented after each incident.