Failure to Prevent Repeated Falls Due to Inadequate Supervision and Care Plan Implementation
Penalty
Summary
The facility failed to provide adequate supervision, assessment, monitoring, and timely revision of care plan interventions to prevent avoidable repeated falls for multiple residents. Four residents with significant fall histories and high-risk factors experienced repeated falls, many of which were unwitnessed and resulted in injuries such as fractures, lacerations, and bruising. In several cases, care plans were either not in place, not updated after falls, or interventions were not consistently followed by staff. For example, one resident with a history of falls and cognitive impairment had 14 falls within a short period, including a major injury resulting in a vertebral fracture, yet did not have a fall care plan in place until after the first fall, and subsequent care plan updates were lacking even after serious injury. Another resident with dementia and a history of falls was left unsupervised in their wheelchair, resulting in a fall that caused a head laceration requiring sutures. Observations showed this resident was left alone for extended periods, their bed was not kept in a low position as care planned, and staff did not consistently follow interventions such as laying the resident down after meals or keeping them at the nurse's station. Incident reports and care plan updates were incomplete or missing, and staff interviews confirmed that care plans were not always followed. A third resident with Parkinson's disease and frequent falls was observed in unsafe situations, such as being left alone in a malfunctioning wheelchair, unable to reach their call light, and wandering unsupervised. This resident experienced multiple unwitnessed falls resulting in head trauma, bruising, and skin tears. Staff interviews indicated a lack of effective intervention updates and insufficient supervision, especially during times of increased resident activity. Another resident with polyneuropathy and unsteady balance was left unattended in the bathroom, attempted to self-transfer, and sustained a toe fracture. Staff reported concerns about insufficient supervision and staffing, and the facility's own policies regarding fall risk assessment and individualized interventions were not consistently implemented.