Failure to Provide Adequate Supervision Resulting in Repeated Falls and Injuries
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent repeated falls for a cognitively impaired resident, resulting in multiple serious injuries. The resident, who had diagnoses including unspecified dementia, mild cognitive impairment, urinary tract infection, and benign prostatic hyperplasia, experienced a series of falls over several weeks. These falls occurred in various locations, such as the bathroom, next to a recliner, and on the floor beside the bed, often when the resident attempted to transfer or ambulate without assistance. The resident's care plan included interventions such as a low bed, floor mat, non-skid socks, 15-minute checks, and staff reminders to use the call light, but these measures did not prevent repeated incidents. The resident was assessed as severely cognitively impaired and required varying levels of staff assistance for activities of daily living, including substantial or maximal assistance for toileting, transfers, and ambulation. Despite this, the resident was frequently found attempting to self-transfer or ambulate without staff help, often due to confusion, urinary urgency, or lack of safety awareness. Several root cause analyses identified issues such as confusion related to a new environment, urinary retention, and discontinued catheter use as contributing factors. In some instances, the resident's call light was found to be nonfunctional, and staff were not always aware of or able to locate the specific fall prevention interventions in place for the resident. Staff interviews revealed inconsistencies in knowledge and communication regarding the resident's fall interventions. Some CNAs were unsure where to find information about fall prevention measures, relying instead on verbal communication or personal familiarity with residents' behaviors. The facility's policy required assessment of fall risk factors and implementation of planned interventions, but the repeated falls and resulting injuries, including multiple fractures and a hospital admission, indicate that adequate supervision and effective interventions were not consistently provided for this resident.