Failure to Implement Fall Prevention Policies and Ensure Adequate Supervision
Penalty
Summary
The facility failed to implement and operationalize fall prevention policies and procedures for two residents, resulting in a lack of planned and meaningful interventions to prevent falls. One resident, who was cognitively intact and required total assistance for bed mobility and transfers, experienced a fall while receiving a bed bath from a single CNA, despite the care plan specifying the need for two staff members. The CNA did not review the resident's care plan prior to providing care and relied on previous training from another CNA. The resident rolled out of bed, which was positioned at waist height without a fall mat in place, and suffered a broken hip requiring emergency surgery. The incident was not immediately reported to the DON as involving a care plan violation, and the DON was unaware of the fracture until the resident returned from the hospital. Another resident, admitted with multiple medical diagnoses including dementia and a history of falls, experienced five falls within a short period. During one incident, the resident was found on the floor next to the bed and subsequently returned to bed without staff assistance. The resident stated he had jumped on the floor to get a drink. After being sent to the hospital, the resident was found to have a rib fracture and a urinary tract infection. The only intervention documented after the incident was to keep drinks within reach, but there was no evidence of a comprehensive fall prevention strategy or meaningful interventions to address the repeated falls. In both cases, the facility did not ensure that staff followed care plans or implemented adequate supervision and interventions to prevent accidents. Staff failed to review care plans before providing care, and there was a lack of assessment for assistive devices or environmental modifications. These failures resulted in residents experiencing falls with injuries, unnecessary pain, and a decline in overall health status.