Failure to Provide Adequate Supervision and Consistent Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to ensure that areas were free from accident hazards and did not provide adequate supervision to prevent accidents for residents identified as high risk for falls. One resident with severe cognitive impairment, hemiplegia, and a history of falls was placed near the nurses' station in a locked wheelchair for observation. Staff left the area unattended, during which time the resident attempted to get up and fell, resulting in a fractured wrist. The resident had experienced multiple falls since admission, and the care plan interventions, such as use of a low bed and activity apron, were inconsistently implemented and not always present during observations. Additionally, the facility did not consistently and accurately document fall prevention interventions for three high-risk residents across care plans, physician orders, and progress notes, as required by facility policy. For example, one resident's care plan included fall mats and frequent rounding, but the physician order sheet did not reflect these interventions, and an incident was not documented in the progress notes. Another resident's care plan did not reflect a recent fall or any new interventions, and observations showed the resident's call light was out of reach and fall risk identification (bracelet) was not in place. Wheelchair safety features, such as roll bars, were also missing despite being listed as interventions. The facility's neurological evaluations post-fall were not maintained in the electronic medical record as required, but instead were kept in a filing cabinet, making them less accessible. Staff interviews revealed inconsistent understanding and implementation of fall prevention measures, with some staff forgetting to provide required interventions like activity aprons or failing to ensure call lights were within reach. The Director of Nursing and other staff acknowledged expectations for consistent documentation and implementation of fall prevention interventions, but these were not met, leading to deficiencies in resident safety and supervision.