Failure to Implement Adequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to develop and implement an adequate care plan with increased monitoring and supervision for a resident who was identified as having poor safety awareness, a history of falls, unsteady gait, and cognitive deficits. Despite being newly admitted with diagnoses including abnormal gait, lack of coordination, hypotension, and aphasia, the resident did not have a fall care plan in place upon admission. Staff relied on a general fall focus system rather than a resident-specific plan, and the resident's needs for supervision and toileting assistance were not sufficiently anticipated or addressed. As a result, the resident was found urinating on the floor and subsequently slipped in his own urine, leading to a fall that caused a bump to the head and a change in consciousness. The resident, who only spoke Mandarin and had limited ability to communicate, was found lethargic and drowsy after the incident and was later diagnosed with intracranial bleeding and admitted to the hospital. Staff interviews confirmed that the resident was unsupervised at the time of the incident, and that the CNA assigned to the unit was attending to another resident. The lack of a tailored fall prevention plan and insufficient supervision directly contributed to the accident.