Failure to Ensure Effective Fall Prevention and Supervision
Penalty
Summary
A deficiency occurred when a resident with impaired cognitive function and a known risk for falls experienced multiple falls within a short period, resulting in significant injuries including bilateral elbow fractures and facial lacerations. The resident was equipped with a pressure alarm intended to alert staff when attempting to get up without assistance. However, on two separate occasions, the alarm failed to sound, and staff did not determine the cause of the malfunction. The resident had a documented history of turning off or moving the alarm, but this was not effectively addressed at the time of the incidents. On the first occasion, the resident was found in another room after getting up unassisted, resulting in a right elbow fracture and a laceration near the right eye that required sutures. The alarm did not sound, and staff were unaware of the resident's movement until after the fall. On the following day, the resident fell again, this time fracturing the left elbow and sustaining another facial laceration. Again, the pressure alarm did not activate, and the fall was unwitnessed. Staff interviews confirmed that the alarm was either not turned on, had been disabled by the resident, or was otherwise ineffective, but no investigation into the alarm's failure was conducted at the time. Documentation and staff interviews revealed that the resident's fall risk was known, and interventions such as bed and door alarms were in place or considered. Despite these measures, the lack of adequate supervision and failure to ensure the functionality of the alarm system directly contributed to the resident's repeated falls and injuries. The facility's policy required evaluation and implementation of interventions to minimize fall risk, but these were not effectively executed in this case.