Failure to Provide Supervision and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure the safety and supervision of residents in two key areas: smoking supervision and fall prevention. Four residents were observed smoking unsupervised in the designated outdoor smoking area, which lacked essential safety equipment such as a fire extinguisher, smoking apron, or smoking blanket. The facility's policy did not require staff-supervised smoke breaks, and residents were not assessed for their ability to smoke safely without supervision. Both the Assistant Administrator and TRC Program Director confirmed that residents were allowed to smoke unsupervised and that no safety equipment was present in the area. In the case of one resident, the facility did not implement or monitor fall prevention interventions as outlined in the care plan. After an unwitnessed fall, the care plan required monitoring of vital signs and blood pressure in lying, sitting, and standing positions, but the medical record showed this was not done. Additionally, following a witnessed fall, the resident was to have bilateral floor pads in place and undergo 24-hour neurochecks. Observations revealed that only one floor pad was in place, and the care plan interventions were not fully individualized or implemented as required. The facility also failed to notify the physician when the resident's neurological status changed, specifically when the resident's speech changed from clear to rambling during neurochecks after a fall. This change was documented in the medical record, but there was no evidence of physician notification or further monitoring of the resident's speech. Interviews with nursing staff and the DON confirmed these lapses in care plan implementation and communication.