Failure to Implement Fall Interventions and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that fall interventions were implemented according to the care plan and that residents received adequate supervision to prevent accidents, as evidenced by the experiences of three residents reviewed for falls and supervision. One resident, who was identified as a fall risk and had a history of 23 falls since admission, experienced repeated falls in similar locations and times, including a fall resulting in a head injury that required sutures. Despite the facility conducting a root cause analysis and collecting data on these incidents, there was no evidence that the interdisciplinary team comprehensively reviewed the data or considered increasing supervision for this resident. The care plan included multiple interventions, such as moving the resident closer to the nurse's station and providing increased monitoring, but these were not consistently or effectively implemented, particularly in the dining room where several falls occurred without increased supervision. Another resident, who was care planned to walk with a walker and have a sign in her room as a reminder, was observed on two separate occasions walking without her walker. Additionally, the required sign was not present in her room, indicating a failure to implement care plan interventions designed to reduce fall risk. This lack of adherence to the care plan placed the resident at increased risk for falls. A third resident, known to have wandering behaviors and a history of acting out toward staff and other residents, was not provided with increased supervision to prevent entry into other residents' rooms. This lack of supervision created a risk for potential resident-to-resident altercations. The facility's fall prevention policy required individualized assessment and implementation of interventions based on risk, but the observed failures in supervision and care plan implementation for these residents demonstrate noncompliance with the policy and regulatory requirements.