Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement appropriate interventions to provide adequate supervision and prevent falls with injury for a resident with a known history of repeated falls and high-risk medication use. The resident, an elderly female with generalized muscle weakness, impaired mobility, moderate cognitive impairment, and a history of falls, was admitted from an acute care hospital. Despite multiple risk factors, including cognitive deficits, incontinence, and use of high-risk medications such as antidepressants, opioids, and antiplatelets, the facility did not timely initiate or update a comprehensive fall prevention care plan. For over six weeks after admission, there was no fall prevention focus in the care plan, and interventions were limited to keeping the call light within reach, which was not appropriate given the resident's cognitive impairment. Observations and interviews revealed that the resident experienced multiple falls during her stay, including an unwitnessed fall from a wheelchair near the nurses' station that resulted in a head laceration requiring emergency care. Staff interviews indicated that while it was common practice to place high fall risk residents near the nurses' station, supervision was inconsistent, especially during busy periods such as medication pass and after dinner. Staff also reported that care plan interventions and safety directives were not always clearly communicated or documented in the electronic record, leading to reliance on verbal reports and inconsistent implementation of fall precautions. Record review and staff statements confirmed that the facility's fall prevention program and protocols were not followed as required. The resident's care plan was not updated in a timely manner to reflect her fall risk, and interventions were not adequately tailored to her needs, particularly given her cognitive impairment and inability to reliably use the call light. The facility's own guidelines required standardized risk assessments, increased supervision, and prompt care plan updates, but these measures were not effectively implemented, resulting in actual harm to the resident.