Failure to Provide Adequate Supervision and Resident-Specific Fall Prevention
Penalty
Summary
A deficiency was identified when the facility failed to provide adequate supervision and implement resident-specific interventions to prevent falls for a resident with a known history of falls, severe intellectual disabilities, developmental delay, and non-compliance with care. The resident was admitted with multiple risk factors, including a recent joint replacement, non-weight bearing status, impulsiveness, combativeness, and inability to follow commands. Documentation from the transferring hospital and facility records consistently noted the resident's high fall risk, cognitive impairment, and need for 24/7 supervision and assistance. Despite these documented risks, the facility's care plans and interventions did not reflect the level of supervision or specific interventions required for the resident's safety. The care plans included general fall prevention strategies such as keeping the bed in a low position, encouraging hydration, and providing non-skid footwear, but did not address the resident's inability to comply with instructions or the need for increased monitoring. Staff and the DON acknowledged the resident's non-compliance and impulsiveness, but interventions such as increased monitoring were only communicated verbally and not documented or clearly defined in the care plan. The facility's policy required individualized assessment and implementation of adequate supervision, but this was not effectively carried out for this resident. The deficiency resulted in an unwitnessed fall, during which the resident sustained significant injuries, including a head laceration, facial bruising, and bleeding, necessitating transfer to the hospital for a higher level of care. The fall occurred despite earlier staff assistance and placement of the call light within reach. The facility's investigation confirmed that interventions for increased observation and supervision were not documented in the care plan, and the root cause analysis did not provide a clear explanation for the failure to prevent the fall.