Failure to Implement Adequate Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to assess and implement appropriate fall interventions for a resident identified as high risk for falls. The resident had a history of falls, impaired cognition, impaired safety awareness, balance and walking impairments, and functional impairments of the lower extremities. The care plan and assessments documented the resident's high fall risk and need for frequent monitoring, supervision, and environmental interventions such as keeping the bed in the lowest position and ensuring the call light was within reach. Despite these documented needs, the resident was left unsupervised for a period of time after being placed in bed, during which an unwitnessed fall occurred. On the day of the incident, the resident was noted to be restless and agitated, refusing to remain in either the bed or wheelchair. Staff and family observed the resident's agitation and attempts to get up, and staff discussed the need for increased supervision, including the possibility of a 1:1 sitter. However, staff did not implement a 1:1 intervention at the time, citing the need for management approval. The resident was left alone after staff believed he had calmed down, but shortly thereafter, a nurse heard a noise and found the resident crawling on the floor with a laceration to the forehead, which required sutures at a local hospital. Interviews with staff and family confirmed that the resident was known to be restless, confused, and at high risk for falls, with a pattern of attempting to get out of bed or the wheelchair. Staff acknowledged the resident's unsafe behaviors and the need for close monitoring, but did not maintain continuous supervision or implement additional interventions in response to the resident's escalating behaviors. The facility's fall prevention policy required individualized interventions for high-risk residents, but these were not fully implemented in this case, resulting in the resident sustaining a significant injury from an unwitnessed fall.