Failure to Provide Adequate Supervision and Assistance Devices to Prevent Resident Falls
Penalty
Summary
A deficiency was identified when a resident with a history of falls, severe cognitive impairment, and significant mobility limitations did not receive adequate supervision and assistance devices to prevent accidents. The resident, who had diagnoses including a left femur fracture, dementia, muscle weakness, and unsteadiness, was assessed as a high fall risk and required maximum assistance with transfers. Despite these needs, the resident experienced two unwitnessed falls after admission, one of which resulted in injury to the head and face. The care plan included interventions such as the use of a gait belt, fall mats, enabler bars, and keeping the call light within reach, but these were not consistently implemented or maintained. Observations and interviews revealed that the resident's call light was frequently not within reach, fall mats and enabler bars were not present as required, and the wheelchair was missing from the room. Staff interviews indicated confusion and inconsistency regarding the resident's care needs, with some staff believing the resident was independent despite documentation indicating a need for moderate to maximum assistance. The Kardex and care plan were not updated to reflect changes in the resident's condition or after the falls, and staff were not always aware of or following the current interventions listed in the care plan. Further, the care plan was not revised after the resident's fall that resulted in injury, and interventions for fall prevention were not added or adjusted. Staff confirmed that required safety devices had been removed without corresponding updates to the care plan, and there was a lack of communication and documentation regarding the resident's fall risk and required interventions. These failures led to the resident not receiving the necessary supervision and assistance devices to prevent accidents, as required by facility policy and the resident's assessed needs.