Failure to Prevent Accidents Due to Inadequate Supervision and Implementation of Fall Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for three residents reviewed for accidents. One resident experienced ten unwitnessed falls, with three of these incidents not being thoroughly investigated for root cause. The majority of these falls occurred when the resident attempted to ambulate to the bathroom independently. Despite being identified as high risk for falls through multiple assessments, the facility did not consistently implement or document fall prevention interventions such as 30-minute checks, urinal at bedside, or the use of non-skid footwear. Additionally, staff statements were not always obtained during fall investigations, and neurological checks were sometimes omitted. The facility also did not conduct a bowel and bladder assessment to establish a toileting pattern, which could have addressed the repeated falls related to bathroom needs. Another resident's fall was not thoroughly investigated, and several fall prevention interventions were not implemented at the time of the incident. The resident was found on the floor without appropriate footwear, and staff failed to ensure the call light was within reach. The care plan required staff to assist with brushing teeth after lunch, maintain a toileting schedule, and use a gait belt for transfers, but these interventions were not observed to be in place. Staff statements regarding the fall were incomplete, and there was a lack of documentation from key personnel who were present at the time of the incident. A third resident was observed with the call light out of reach and was given straws despite having an aspiration risk. These observations occurred during the survey process and were contrary to the resident's care plan and safety requirements. The facility's failure to implement and monitor individualized interventions, conduct thorough investigations, and ensure staff adherence to care plans contributed to the deficiencies in accident prevention and resident safety.