Failure to Implement Fall and Accident Prevention Interventions
Penalty
Summary
The facility failed to implement appropriate accident and fall prevention interventions for a resident with significant cognitive impairment and multiple medical conditions, including cerebral infarction, encephalopathy, diabetes, chronic embolism, seizures, and substance abuse. Upon admission, the resident was noted to be oriented to person only, unable to follow directions, and had a history of impulsive behaviors such as pulling out medical equipment and attempting to get up unassisted. Hospital discharge documentation indicated the need for a bed alarm and one-to-one sitter, but these interventions were not consistently implemented in the facility. Despite being identified as at risk for falls and removal of medical equipment, the resident's care plan and progress notes lacked adequate and timely interventions to address these risks. The resident experienced multiple incidents, including pulling out a gastrostomy tube on two separate occasions, both requiring hospital visits for reinsertion, and sustaining falls, one of which resulted in a laceration above the left eyebrow that required sutures. After each incident, there was little evidence of new or enhanced interventions being put in place to prevent recurrence, and documentation did not reflect the use of a bed alarm or one-to-one supervision as recommended at discharge. Interviews with facility staff confirmed that the resident was impulsive, had poor safety awareness, and was unable to use the call light due to cognitive impairment. Staff acknowledged that the resident needed one-to-one care and a bed alarm, but these measures were not provided. The lack of appropriate supervision and failure to implement individualized safety interventions directly contributed to the resident's repeated accidents, including falls and the removal of the feeding tube.