Failure to Prevent Accidents and Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents at high risk for falls and injury received adequate supervision and assessment to prevent accidents. One resident with a history of neurocognitive disorder, brain injury, and moderate cognitive impairment experienced four falls within a short period, two of which required emergency department evaluation. After a fall resulting in a pelvic fracture, there were no immediate changes to the resident's fall prevention care plan, and the resident was allowed to participate in an outing on the same day as another fall. The resident was not provided with a means to call for assistance in common areas, and there was no assessment of her ability to understand or use fall prevention interventions, despite her cognitive deficits. Another resident with Alzheimer's disease, right-sided paralysis, and a history of falls was transported by her spouse to an appointment, during which she fell from her power wheelchair and sustained a head laceration and thoracic spine fracture. The facility had not assessed her ability to safely operate power-mobility equipment, nor was there documentation of care plan review or revision after the fall. There was also no evidence that the facility provided education to the spouse regarding safe transfers or supervision during outings. Facility policy required prompt assessment, care plan updates, and interdisciplinary team (IDT) review after falls, but documentation revealed delays or omissions in these processes. Staff interviews confirmed gaps in communication, monitoring, and documentation of fall reviews and interventions. The lack of timely care plan updates, supervision, and individualized assessment contributed to repeated falls and injuries for both residents.