Failure to Monitor and Document Supervision for High Fall Risk Resident
Penalty
Summary
Facility staff failed to adequately monitor and supervise a resident identified as high fall risk, resulting in three unwitnessed falls within a single month. The resident had multiple diagnoses, including osteoarthritis, psychotic disorder, syncope, muscle weakness, and a history of falls, and was prescribed several high fall risk medications such as Ambien, Eliquis, Depakote, and Clonazepam. Despite these risk factors, there was no documented evidence that staff maintained a written log of regular monitoring or rounding as required by facility policy, nor were medication regimens reviewed or adjusted after the initial fall. The facility's policies required a fall risk assessment on admission and at least quarterly, with additional assessments after any fall, and mandated regular rounding with documentation of date, time, staff, and observations. However, staff interviews revealed that while CNAs and nurses claimed to round on the resident every one to two hours, there was no documentation in the electronic health record or written logs to verify these rounds. The lack of documentation persisted across all three falls, and staff acknowledged that there was no system in place for CNAs to record their rounds, contrary to policy requirements. After each fall, assessments indicated the resident remained at high risk, but no changes were made to the medication regimen until after the second fall. The third fall resulted in a significant injury, with the resident sustaining fractures to the right ankle. Throughout these incidents, the facility did not provide evidence of consistent monitoring or timely response as outlined in their own procedures, nor did they document interdisciplinary team actions to address the resident's ongoing fall risk.