Failure to Prevent Resident Falls Due to Inadequate Supervision and Device Maintenance
Penalty
Summary
The facility failed to ensure that residents remained as free from accidents as possible, specifically related to falls, for three sampled residents by not maintaining assistive devices, providing adequate supervision, or implementing timely and effective interventions. One resident, who had a history of falls and moderate cognitive impairment, was care planned to use a wheelchair seat belt as a fall reminder. Despite staff and maintenance being aware that the seat belt was broken and improperly secured for several days, no effective intervention was implemented, and the resident suffered a fall resulting in multiple fractures and significant pain. The maintenance log system was not properly utilized, and the broken equipment was not tracked or repaired in a timely manner, with the resident left without a functioning seat belt until after the incident. Another resident with mild dementia and a history of falls experienced nine unwitnessed falls over a short period. Despite repeated incidents, the care plan was not updated with new interventions after each fall, and changes were delayed by up to 28 days. Documentation and monitoring of interventions were lacking, and the resident continued to fall without evidence of effective preventive measures being implemented or tracked in a timely manner. A third resident, dependent on staff for self-care and with severe cognitive impairment, experienced four unwitnessed falls in one month. Although some interventions were added to the care plan, they were often repeats of previous measures and not new or tailored to the resident's changing needs. The resident was left unattended in high-risk areas despite a known history of getting up unassisted, and after a fall resulting in a facial laceration and ER transfer, no new interventions were created. The DON confirmed that care plans were not updated as required after each fall, and there was no evidence of consistent implementation or monitoring of fall prevention strategies.