Failure to Provide Timely Assessment and Supervision for High-Risk Fall Resident
Penalty
Summary
A deficiency occurred when a resident with dementia, a brain tumor, and osteoporosis, who was assessed as high risk for falls, did not receive care and treatment in accordance with professional standards and their person-centered care plan. The resident experienced two unwitnessed falls in one day. After the first fall, which occurred early in the morning, the resident was found on the floor by an LPN. The LPN took the resident’s vital signs, cleaned them, and assisted them into a chair, but there was no documentation that a registered nurse assessed the resident, that a medical provider was notified, or that emergency medical services were contacted, as required by facility policy when no RN is present. The incident was not reported to the appropriate personnel until later in the day, after a second fall occurred and a registered nurse was notified by a certified nurse aide. Repeated observations over two days showed that the resident’s call bell was consistently clipped to the privacy curtain and not within reach while the resident was in bed or in their wheelchair. The care plan and facility policy required that the call bell be within reach at all times, especially for residents at high risk for falls. Staff interviews confirmed that the call bell was not accessible to the resident and that this was not in accordance with policy. Staff also acknowledged that the resident was capable of using the call bell but did not do so, further emphasizing the importance of ensuring accessibility. Additionally, the resident was observed transferring themselves between bed, wheelchair, and bathroom without staff assistance, despite care plan interventions requiring supervision and assistance with toileting. On one occasion, an LPN observed the resident alone in the bathroom but did not assist or notify anyone, leaving the resident unsupervised. These actions and inactions were inconsistent with the resident’s care plan and the facility’s fall prevention policy, contributing to the deficiency.