Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and staff assistance to prevent injuries from falls for a resident with a significant fall history and severe cognitive impairment. The resident had multiple diagnoses, including repeated falls, Wernicke's encephalopathy, alcohol dependence with withdrawal delirium, arthritis, and severe cognitive impairment as indicated by a low BIMS score and symptoms of delirium. The resident required moderate staff assistance for transfers and personal care, was at high risk for falls as documented by repeated high scores on fall risk assessments, and had experienced 20 falls over a four-month period, with half of these occurring unwitnessed in the resident's room. Several of these falls resulted in serious injuries requiring hospitalization, including subdural hematoma, skull fracture, and multiple fractures with hemothorax. The facility's care plan included various interventions such as regular safety rounding, keeping the call light within reach, environmental modifications, and encouraging the resident to request assistance. However, the resident was often noncompliant with these interventions, preferring independence and frequently refusing assistance or environmental cues. Staff interviews confirmed that the resident insisted on keeping his room door closed, making it difficult for staff to monitor him, and that staff were hesitant to disturb him due to his agitation when awakened. Despite the high risk and repeated falls, there was no evidence of increased direct supervision or implementation of additional monitoring strategies, such as the use of a baby monitor, to address the resident's specific behaviors and preferences. Additionally, the facility failed to involve the resident's family or legal representative in required care conferences, despite repeated requests from the family for increased supervision and specific fall prevention interventions. The family and POA reported not being invited to participate in care planning and expressed concerns that their input regarding safety measures was not considered. The facility also reinstated medications that increased the resident's fall risk, contrary to hospital discharge instructions, and did not document any alternative strategies to mitigate these risks. These actions and inactions contributed to the resident's continued falls and serious injuries.