Failure to Provide Adequate Supervision and Assistance Devices for Resident with Fall History
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices for a resident with a history of multiple falls. The resident, who had diagnoses including dementia, psychotic disturbance, anxiety, frontal lobe and executive function deficit, Parkinson's disease, and spondylosis, was assessed as not cognitively impaired and had a corporate guardianship for healthcare decisions. The resident's care plan required limited assistance with bed mobility and transfers, supervision with toilet hygiene, and the use of a wheeled walker and gait belt, with the bed to be kept in a low position. Despite these interventions, the resident experienced seven unwitnessed falls over six months, and observations revealed that the resident was allowed to ambulate and transfer independently in their room, with the bed not maintained in a low position as specified in the care plan. Interviews with staff indicated inconsistency in following the care plan, with some staff stating the resident was independent with transfers and toileting, while others noted a preference to assist due to hygiene concerns. The resident reported being independent with these activities, and staff acknowledged that the resident did not always call for assistance as required. The Director of Nursing confirmed that staff are expected to follow residents' care plans, but the observed practices did not align with the documented interventions, contributing to the repeated falls.