Failure to Prevent Falls and Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of effective interventions to prevent accidents and falls for two residents with cognitive impairment and a history of frequent falls. One resident with severe dementia experienced five unwitnessed falls over a period of time, with the facility failing to update or modify care plan interventions after each incident. The interventions remained limited to environmental reminders, such as signage and call bell placement, despite the resident's known tendency to self-transfer and not use the call bell. Staff interviews confirmed that the resident was impulsive, required assistance with transfers, and was becoming increasingly weak, yet no new or enhanced interventions were documented or implemented following repeated falls. On one occasion, the resident was found unresponsive, unclothed, and cold on the floor of their room after an unwitnessed fall. The resident's body temperature was unmeasurable, oxygen saturation was critically low, and they were subsequently hospitalized with hypothermia, acute respiratory failure, and septic shock, ultimately resulting in death. Staff interviews revealed that the resident was not being monitored more frequently despite illness and a history of falls, and there was no formal protocol for increased checks or rounding for high-risk residents. Documentation showed that staff were not provided with additional training or guidance following the incident, and care plans were not revised to address the ongoing risk. A second resident with moderate cognitive impairment and Parkinson's disease sustained 30 falls, 20 of which were unwitnessed, over a documented period. The care plan lacked active interventions for transfer and ambulation status, and there was no evidence of monitoring the effectiveness of interventions or modifying them as necessary. Staff interviews indicated that there was no formal rounding protocol or increased monitoring for residents with repeated falls. The facility's own policies required aggressive monitoring and intervention for high-risk residents, but these were not followed, resulting in substandard quality of care and actual harm.
Removal Plan
- Reviewed fall care plans for residents identified as having a high risk for falls.
- Reviewed care Kardex for residents identified as having a high risk for falls.
- Educated staff on the systematic changes and policy review (accidents and incidents prevention, investigation, hourly checks, communicating to the emergency management system and hospital system).
- Educated all active employees on these systemic changes and policy reviews.
- Ensured no staff reported to active duty without having this education.
- Held a Quality Assurance Performance Improvement meeting.
- Educated Certified Nurse Aides, Licensed Practical Nurses, and Registered Nurses regarding the new policy involving hourly checks for residents identified as increased risk for falling.
- Certified Nursing Assistants documented completion of hourly checks for the identified residents in a binder at the nursing station.
- Nursing staff verified completion of this task at shift completion.
- All staff interviewed verbalized understanding of the new policy and procedures involving hourly rounding on residents identified as having a high risk for falls.