Failure to Provide Consistent Supervision Results in Multiple Unwitnessed Falls
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent avoidable falls for a cognitively impaired resident with a history of falls, recent brain bleed, poor safety awareness, and impulsiveness. The resident was assessed to require staff supervision at bedside, but this intervention was not consistently implemented. Multiple unwitnessed falls occurred, including incidents where staff left the resident unsupervised, resulting in serious injury, including a new subacute subdural hematoma that required hospitalization and intensive care. The resident's care plan included interventions such as a fall mat, bed against the wall, helmet, non-skid footwear, and 1:1 supervision at bedside. Despite these interventions being documented, staff interviews and record reviews revealed that 1:1 supervision was only provided when extra staff were available. Staff members reported that they were not required to find relief before leaving the resident unsupervised, and there was confusion among the nursing administration regarding the necessity and implementation of continuous 1:1 supervision as outlined in the care plan. Incident logs and staff interviews confirmed that the resident experienced multiple unwitnessed falls when supervision was not maintained as required. Staff acknowledged that the presence of a sitter at bedside was effective in preventing falls, but this intervention was not reliably provided. The lack of consistent supervision placed the resident at risk for further injury and demonstrated a failure to implement and monitor care plan interventions as required.