Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate nursing supervision and implement effective interventions to prevent falls for a resident with a known history of repeated falls and high fall risk. The resident, who had progressive neurological conditions, hypertension, and depression, experienced eight falls over several months. Despite being assessed as requiring partial to moderate assistance with mobility and transfers, the resident was frequently left unattended or allowed to self-transfer, particularly when returning to her room after meals. The care plan included interventions such as encouraging the resident to use the call light, ensuring appropriate footwear, moving her room closer to the nurse's station, and providing additional call lights, but these measures were inconsistently implemented or ineffective. Multiple incidents documented that staff did not always follow the care plan or facility policy. For example, the resident was left alone on the toilet, not provided with a gait belt during transfers, and staff failed to consistently monitor her movements after meals. The use of a floor mat alarm was delayed due to equipment compatibility issues, and when it was eventually implemented, it was later removed because it was not functioning properly and the resident or her husband would move it out of the way. There was a lack of additional interventions during the period when the floor mat alarm was unavailable. Staff interviews revealed that the resident was known to be impulsive and quick, often leaving the dining room unassisted, and staff were not always able to anticipate or intercept her movements in time to prevent self-transfers. The resident sustained significant injuries as a result of these falls, including a laceration to the forehead requiring emergency care and a left hip fracture that necessitated surgical intervention. Documentation showed that staff education following falls was often verbal and not formally recorded, and there was confusion among staff regarding the implementation and timing of interventions such as auto-lock brakes and alarms. The facility also experienced staff turnover and use of agency staff, which may have contributed to inconsistent supervision and adherence to the care plan. The cumulative effect of these actions and inactions resulted in the resident suffering repeated falls, injuries, and ultimately a decline in health following the final fall and subsequent surgery.