Failure to Prevent Falls and Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to properly assess for safety, implement timely and effective interventions, and provide adequate supervision to prevent accidents for a resident identified as high fall risk, a wanderer, and with severe cognitive impairment. The resident had a history of falls with injury and was completely dependent on staff for mobility and transfers. Despite these risks, the resident experienced multiple falls, including incidents on a staircase that resulted in multiple facial fractures, a laceration requiring closure, loss of consciousness, hospitalization, and unnecessary pain. The facility did not ensure the environment was free from accident hazards, as the stairwell was open and accessible to cognitively impaired residents without any deterrents in place at the time of the incidents. Interviews and record reviews revealed that the facility did not follow the resident's care plan, which included interventions such as a perimeter mattress and a soft helmet. The resident was observed without a perimeter mattress or helmet at the time of the falls, and staff were unable to explain why these interventions were not in place. Documentation of the incidents was incomplete or delayed, with missing progress notes, lack of vital sign documentation, and late entries in the medical record. The facility also failed to notify the State Agency of the incidents involving major injuries in a timely manner. Additionally, the facility did not involve the resident's Power of Attorney (POA) in care decisions or care planning, including the initiation of hospice services and notification of falls. The POA reported not being informed of significant events, including additional falls, and expressed concerns about the lack of communication and coordination with the facility. The combination of inadequate supervision, failure to implement care plan interventions, lack of environmental safeguards, and poor communication contributed to the resident's repeated injuries and decline.
Removal Plan
- Nurse management team completed new fall risk assessments for all like residents.
- The interdisciplinary team updated all current resident's plans of care based on new risk assessments.
- Stop sign barrier banners have been placed at the entrance way of the stair well on ascending and descending sides to impede resident usage.
- Measurements for the stairwell have been taken by the Maintenance Director to research and implement a more permanent solution.