Failure to Provide Adequate Supervision and Accident Prevention for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to ensure the safety of a resident with a history of traumatic brain injury, severe cognitive impairment, and repeated falls. Despite multiple documented incidents of falls and self-injurious behaviors, such as pulling out a PEG tube, the interdisciplinary team did not implement consistent or sufficient interventions to prevent further accidents. The resident experienced several unwitnessed falls in various locations, including the resident's room, hallway, and dining room, often due to confusion, restlessness, and attempts to self-transfer or move unassisted. Facility records and staff interviews revealed that interventions were reactive and often implemented only after each incident, such as adding a perimeter mattress, fall mats, or removing wheelchair footrests. The care plan was updated multiple times, but the resident continued to experience falls and incidents of self-harm. Staff acknowledged the resident's high risk for accidents due to confusion, physical strength, and inability to follow directions, yet one-to-one supervision was not provided until after a hospitalization, and only as a temporary measure during the transition back to the facility. Interviews with facility staff, including the DON, ADON, and unit manager, indicated uncertainty and inconsistency regarding the use of 1:1 supervision and the facility's responsibility to provide it when family was unable to do so. The facility's policies required targeted interventions and adequate supervision for residents at risk, but these were not consistently or proactively applied for this resident, resulting in repeated accidents and injuries.