Failure to Provide Adequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, as well as to conduct thorough fall investigations. Review of the clinical record and fall reports for a resident with a history of wedge compression fracture, unspecified fall, and unsteadiness on feet revealed multiple incidents where staff did not follow the care plan interventions. Specifically, during two separate falls, staff did not utilize the sit-to-stand (sts) lift as required by the resident's care plan. Additionally, after one of these falls, the responsible RN did not notify the Director of Nursing (DON) as per facility protocol, resulting in an incomplete investigation and lack of witness statements. Further review showed that after another fall, a new intervention was documented in the fall report but was not added to the resident's comprehensive care plan. Interviews with the DON confirmed that expected procedures, such as updating the care plan and collecting witness statements, were not followed. These failures demonstrate lapses in both the implementation of fall prevention interventions and the facility's post-fall investigation process.