Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of meaningful interventions to prevent falls for two residents with severe cognitive impairment and significant mobility deficits. One resident, who was under hospice care with multiple diagnoses including congestive heart failure, diabetes with neuropathy, vascular dementia, and end-stage renal disease, required substantial assistance for mobility and transfers and had visual impairment. Despite these needs, the resident's care plan did not address safety and monitoring after dialysis or when left unsupervised in a chair. The resident experienced an unwitnessed fall after returning from dialysis, with the wheelchair brakes found unlocked and no documentation of supervision, call light accessibility, or recent toileting. Staff interviews revealed uncertainty about the resident's supervision and lack of clear interventions to prevent falls after dialysis. Another resident with a history of falls, severe cognitive impairment, and substantial assistance needs for transfers and mobility experienced multiple falls, including one resulting in a hip fracture. The care plan included general fall prevention interventions, but documentation and staff interviews indicated that these were not consistently or effectively implemented. The resident was frequently left unsupervised near the nurses' station without activities or a call light, and staff were not always present or able to observe the resident. Incident and accident forms lacked critical details such as last toileting, footwear, continence status, and staff presence at the time of falls. Post-fall evaluations and investigations were incomplete, with discrepancies in documentation and unclear root causes for the falls. Staff interviews and record reviews highlighted gaps in supervision, incomplete investigations, and insufficient communication regarding interventions and staff assignments. The facility did not provide adequate documentation of staff presence or actions taken at the time of the incidents, and there was a lack of meaningful, individualized interventions following repeated falls. The failure to provide adequate supervision and implement effective fall prevention strategies resulted in preventable injuries, including a hip fracture, for residents at high risk due to cognitive and physical impairments.