Failure to Consistently Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident identified as high risk for falls received adequate supervision and that person-centered fall prevention interventions were consistently implemented. The resident, who had dementia, repeated falls, muscle weakness, and severe cognitive impairment, was admitted for long-term care and assessed as a high fall risk. The care plan included one-to-one supervision at arm's length, use of a pressure-sensitive bed alarm, and other fall prevention measures. Despite these interventions being documented, staff did not consistently follow them. On two separate occasions, the resident sustained unwitnessed falls. The first fall occurred when the resident was found on the floor with a head injury, and the care plan was updated to require a one-to-one caregiver. However, the second fall happened when the resident was again left unattended, resulting in a head laceration and rib fractures, and required hospital evaluation. Observations revealed that the assigned caregiver was not always within arm's length of the resident as required, and the pressure-sensitive bed alarm was not in place. The resident was left alone in his room and in the television room without direct supervision, contrary to the care plan directives. Interviews with staff confirmed that the one-to-one caregiver was aware of the need to remain close to the resident but left him unattended due to staffing constraints and personal needs. Other staff members and facility leadership acknowledged the importance of close supervision for this resident and recognized that the interventions were not consistently implemented. The facility's own policies required individualized interventions for high-risk residents, but these were not reliably followed, directly leading to the resident's repeated falls and injuries.