Failure to Provide Adequate Supervision for Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident with dementia, mood disorder, anxiety, and a history of falling. Clinical records indicated that the resident was cognitively impaired, had impulsive behaviors, and was identified as being at risk for falls in both the care plan and fall risk assessments. Despite these documented risks, the resident experienced six falls over a five-month period, including multiple incidents of falling out of bed and out of chairs in various areas of the facility. Some of these falls resulted in injuries, such as a lump on the forehead, and one incident required hospital evaluation. The repeated falls demonstrate that staff did not provide sufficient supervision or interventions to prevent accidents for this high-risk resident.