Failure to Consistently Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to administer its resources effectively and efficiently for a resident with a significant fall risk, resulting in a deficiency. A cognitively impaired resident with a history of repeated falls, recent brain bleed, poor safety awareness, and impulsiveness was assessed to require staff supervision at bedside. Despite this, the intervention of a sitter at bedside was not consistently implemented, and the resident experienced multiple unwitnessed falls while unsupervised. Documentation showed that the care plan included interventions such as sitters at bedside, helmet use, and frequent neurological checks, but these were not reliably carried out. Staff interviews revealed that sitters were only provided when extra staff were available, and there was no system to ensure continuous supervision as indicated in the care plan. Staff members reported that if a sitter needed to take a break, there was no requirement to find a replacement, leaving the resident unsupervised. The Assistant Director of Nursing acknowledged that interventions were copied from incident reports into care plans without specifying duration or end dates, leading to confusion about the ongoing need for supervision. The Director of Nursing and other staff confirmed that 1:1 supervision was not always provided, and the nurse practitioner’s recommendation for continuous supervision was not consistently followed. As a result of these lapses, the resident suffered several unwitnessed falls, including one that resulted in a new subacute subdural hematoma and required admission to the neurological intensive care unit. The lack of consistent implementation of care plan interventions and inadequate communication among staff contributed directly to the repeated incidents. The deficiency was identified as Immediate Jeopardy due to the likelihood of serious injury, harm, impairment, or death for the resident and potentially for others requiring increased supervision.