Failure to Prevent Accidents and Ensure Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents at high risk for falls received adequate supervision and assistance devices to prevent accidents. One resident with Parkinson's Disease, Lewy body Dementia, and congestive heart failure experienced multiple unwitnessed falls. The facility did not thoroughly investigate each fall to determine the root cause or confirm that all care plan interventions were in place and effective at the time of the incidents. Documentation revealed that the resident often attempted self-transfers despite being care planned for staff assistance and the use of a Hoyer lift. Investigations into the falls lacked critical information, such as call light response times, whether the bed was in the lowest position, and if other interventions were implemented. In several instances, the resident activated the call light as instructed, but still experienced a fall before staff arrived, and the effectiveness of this intervention was not evaluated. Another resident with severe cognitive impairment, a history of falls, and recent physical decline was not consistently provided with the required level of assistance for transfers and toileting. The care plan specified the use of a mechanical lift (Hoyer) with two staff for all transfers and a prompted toileting program to reduce self-transfer attempts. However, staff interviews and observations revealed that the resident was transferred by a single staff member without a gait belt, and the prompted toileting program was not consistently followed. Staff were not always aware of the resident's current transfer and toileting requirements, and documentation indicated that the resident continued to self-transfer, increasing the risk of falls. The facility's failure to ensure that care plan interventions were implemented and effective, to thoroughly investigate falls, and to provide adequate supervision and assistance devices for residents at high risk for falls resulted in repeated incidents. Staff interviews indicated a lack of awareness and communication regarding residents' care plans and interventions, and investigations did not consistently review whether all safety measures were in place at the time of each fall.