Failure to Provide Adequate Supervision and Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who experienced four unwitnessed falls within seven days, three of which occurred after her indwelling catheter was not replaced. Despite the facility's fall management policy requiring increased observation and structured routines for residents with multiple falls, the care plan was not updated with new interventions. Nurses did not complete required neurological assessments or alert charting for 72 hours after each unwitnessed fall, and there was no individualized toileting program or bladder assessment after the catheter was removed. These omissions occurred even though the resident had a history of moderate cognitive impairment, muscle weakness, difficulty walking, and was on medications that increased her risk for falls and bleeding. The resident's medical records indicated she required moderate assistance with transfers, toileting, and walking, and had been recommended for 24-hour supervision by therapy staff. After the catheter was not replaced, the resident attempted to toilet herself frequently, leading to repeated falls. Staff interviews revealed that the resident did not use her call light, often shut her door, and needed frequent checks, but there were no special instructions or documented safety checks. Staff also reported insufficient training on updating care plans and a lack of consistent interventions such as one-on-one supervision or increased monitoring, despite recognizing the resident's high fall risk. Following the series of falls, the resident developed a head injury that progressed to a brain bleed, ultimately resulting in hospitalization and death. Documentation reviews confirmed that required post-fall assessments, neurological checks, and care plan updates were not completed as per facility policy. The Director of Nursing and other staff acknowledged these failures, including the lack of a bladder training program and the absence of new interventions after each fall, which were required by the facility's own policies and procedures.