Failure to Supervise High Fall Risk Residents Resulting in Serious Injuries
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards for two residents, resulting in significant injuries and hospitalizations. One resident, with diagnoses including Alzheimer's disease and a history of falls, was found sitting unsupervised on the side of her bed with the bed not in the lowest position, the bed alarm not sounding, and her call light out of reach. This resident later fell in the bathroom while attempting to ambulate independently, despite care plan interventions requiring staff supervision during transfers and toileting. Staff interviews confirmed that the resident was known not to use her call light and required supervision, but she was left unattended, leading to a left hip fracture. Another resident, also with a history of repeated falls, cognitive impairment, and hemiplegia, experienced multiple falls over a period of time, including a significant incident where she fell off the toilet while attempting to clean herself, resulting in a right frontal laceration that required hospitalization and sutures. The resident's care plan specified that staff should remain with her in the bathroom and not leave her unattended, but documentation and staff interviews revealed that she was left alone or given privacy, contrary to these interventions. The resident's fall risk assessments consistently rated her as high risk, and her medical records documented frequent reminders and interventions that were not consistently followed. Staff interviews indicated that both residents rarely used their call lights and often attempted to perform tasks independently despite their high fall risk and care plan requirements for supervision. Staffing levels were noted to be low, with only one CNA for a hallway of 23 residents during certain shifts, making it difficult to provide the required supervision. The facility's own falls policy required individualized care planning and consistent implementation of fall prevention interventions, which were not adhered to in these cases, directly contributing to the residents' injuries.