Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure a safe and secure environment for multiple residents at risk for falls and accidents, as evidenced by inadequate supervision, incomplete fall investigations, and failure to implement or maintain appropriate interventions. Several residents with cognitive impairments and mobility issues experienced repeated falls, with one resident sustaining multiple serious injuries including a subdural hemorrhage, cervical fracture, and bilateral rib fractures after a series of unwitnessed and unassisted falls. The facility did not consistently conduct thorough fall investigations to identify all contributing factors or root causes, and did not always update or implement individualized care plan interventions following each incident. Documentation revealed that neuro checks and vital signs were not completed according to the facility's own neuro check guidelines after unwitnessed falls or falls with potential head injury. In several cases, neuro checks were either not initiated, not performed at the required intervals, or not documented at all. Additionally, witness statements were not always obtained, and fall interventions such as fall mats were not consistently present in resident rooms despite being listed in care plans. Staff interviews confirmed that some interventions were not in place and that there was confusion or lack of adherence to fall investigation and documentation protocols. The facility's failure to provide adequate supervision and maintain an environment free from accident hazards resulted in Immediate Jeopardy for at least one resident, who was highly vulnerable due to severe cognitive impairment and mobility issues. The lack of timely and thorough investigations, incomplete documentation, and failure to implement or maintain appropriate safety interventions contributed to repeated falls and serious injuries among residents. These deficiencies were identified through policy review, medical record review, observation, and staff interviews during the survey.