Failure to Prevent Accidents Due to Inadequate Supervision and Incomplete Fall Investigations
Penalty
Summary
The facility failed to ensure that two residents received adequate supervision and assistance devices to prevent accidents, as required by policy. Both residents had a history of falls and were identified as being at risk, yet the facility did not conduct thorough investigations following multiple fall incidents. For one resident, repeated self-transferring behaviors were documented, but these were not addressed in the care plan, and interventions were not updated to reflect the ongoing risk. The facility's investigations into the falls did not consistently include key information such as who last observed the resident, what the resident was doing prior to the fall, when the resident was last toileted, or whether prior interventions were in place and effective at the time of the incident. In several instances, the facility's documentation and investigative process were incomplete. Staff statements were not always obtained or included in the investigation packets, and there was a lack of evidence that staff were interviewed regarding the circumstances of the falls. The care plans for the residents did not address self-transferring behaviors, despite staff being aware of these actions. Additionally, interventions such as offering toileting with every interaction were not consistently communicated to or implemented by direct care staff, as observed by the surveyor during interviews and record reviews. The residents involved had significant medical histories, including cognitive impairment, hemiplegia, diabetes, and chronic kidney disease, which increased their vulnerability to falls and injuries. Despite these risk factors, the facility did not ensure that all fall prevention interventions were in place or that staff were adequately informed of changes to care plans. The lack of thorough investigation and failure to address known risk behaviors contributed to repeated falls and, in one case, a pelvic fracture requiring hospitalization.