Failure to Provide Consistent Supervision for High-Risk Resident
Penalty
Summary
A facility failed to develop and consistently implement an adequate safety plan and provide sufficient supervision for a resident with a significant history of falls and severe cognitive impairment. The resident was admitted with multiple serious injuries from a prior fall, including intracerebral and subdural hemorrhages, spinal and rib fractures, and a right orbital fracture. Upon admission, the resident was noted to be restless, impulsive, and required staff assistance for all activities of daily living, with a care plan that included a one-on-one sitter due to high fall risk. Despite these interventions being documented, the facility did not consistently provide the required one-on-one supervision. Throughout the resident's stay, there were at least ten documented falls, several resulting in injuries such as hematomas, lacerations, and bruising, and requiring emergency department evaluation. Progress notes and interviews revealed that the resident was frequently agitated, difficult to redirect, and continued to attempt to stand or move unassisted. Staff and medical providers repeatedly documented the resident's need for close supervision, yet the one-on-one sitter was removed at some point prior to a significant fall, contrary to the established care plan. Staff interviews confirmed that the removal of the sitter was a management decision, and that the resident's supervision was insufficient during this period. The facility's administration acknowledged to the resident's legal guardian and to surveyors that they could no longer provide the one-on-one supervision as outlined in the care plan, and even requested the guardian to provide or pay for additional supervision. There was no documentation of a revised strategy or adequate alternative supervision plan, and the facility failed to ensure the care plan interventions were followed. The facility's own policy required individualized supervision based on assessed risk, but this was not adhered to, resulting in repeated falls and injuries for the resident.