Failure to Prevent Falls and Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that effective fall prevention interventions were implemented and maintained for two residents identified as high risk for falls, resulting in multiple falls with major injuries. One resident, with severe cognitive impairment and a history of fractures, experienced four falls since admission, including incidents that resulted in a left elbow fracture requiring surgery and a pubic ramus fracture. Despite documented interventions such as a hi/low bed, call light within reach, frequent checks, and use of hip protectors, the resident continued to experience unwitnessed falls both in their room and in common areas. Staff interviews revealed that post-fall huddles were not consistently conducted, and there was a lack of verification of serious injury and neglect allegations, as the facility believed the care plan was followed and supervision was adequate. Another resident, also with severe cognitive impairment and a history of falls, suffered multiple falls resulting in injuries, including a lumbar compression fracture. The care plan included interventions such as non-skid socks, therapy evaluation, routine rounding, and use of a helmet and hip protectors. However, the resident was observed barefoot and fell in the hallway, and was later found on the dining room floor after another fall. Documentation showed that the resident had been hospitalized three times for recurrent falls, and staff were instructed to encourage the resident to remain in common areas, but falls continued to occur. The facility's fall prevention and post-fall assessment policies required individualized risk assessments, implementation of appropriate interventions, and review and revision of care plans following falls. However, interviews with staff indicated inconsistent knowledge and application of fall reduction programs and interventions, such as compassionate touch techniques. The facility's Fall Reduction Program was still under development and lacked a formal policy or procedure, and not all staff had received training on key interventions. These deficiencies in supervision, intervention effectiveness, and staff training contributed to the continued occurrence of falls with major injuries among high-risk residents.