Failure to Provide Adequate Supervision and Post-Fall Assessment
Penalty
Summary
The facility failed to ensure adequate supervision and the use of assistive devices to prevent accidents for four out of five residents reviewed for falls. Multiple residents with significant cognitive and physical impairments experienced repeated falls, and the facility did not consistently perform thorough post-fall assessments, update care plans with each incident, or implement timely interventions. For example, one resident with Parkinson's disease and dementia had at least eight falls, with records frequently lacking post-fall neurological checks and falls assessments. Interventions such as anti-rollbacks for wheelchairs and reminders for staff to use gait belts were often delayed in being added to care plans, and some interventions were not implemented at the time of the falls. Another resident, who was legally blind and had a seizure disorder, experienced several falls, including unwitnessed incidents resulting in head injuries. Documentation showed that neurological checks were incomplete or missing after some falls, and falls assessments were not performed. Observations revealed that staff did not always follow care plan interventions, such as ensuring the call light was clipped to the resident's clothing for safety. Transfers were sometimes performed by a single staff member despite care plan requirements for two-person assistance. Additional residents with diagnoses such as Alzheimer's disease, dementia, and schizophrenia also experienced multiple falls. In several cases, the facility did not document interdisciplinary team reviews or update care plans with new interventions after falls. Neurological checks were inconsistently performed or not documented, and falls risk assessments were often omitted following incidents. Observations further indicated that assistive devices, such as call lights, were not always accessible to residents as required by their care plans. Facility policies required neurological assessments and care plan updates after falls, but these were not consistently followed.