Failure to Provide Adequate Supervision and Fall Prevention for Residents at Risk
Penalty
Summary
The facility failed to ensure that residents at risk for falls received adequate supervision and timely, appropriate interventions to prevent accidents. Two residents with a history of falls experienced multiple unwitnessed falls, with one resident suffering a subdural hematoma. Despite repeated incidents, the facility did not complete thorough post-fall assessments, root cause analyses, or timely updates to care plans. Documentation was often incomplete, with missing or partially filled vital signs and neurological check sheets, and post-fall assessments were sometimes delayed by weeks. For one resident with cognitive impairment, lymphedema, atrial fibrillation, and a history of repeated falls, there were seven unwitnessed falls while self-transferring. The facility did not conduct immediate or comprehensive assessments after these falls, nor did it update the resident's care plan with new interventions. The interdisciplinary team (IDT) reviews and root cause analyses were either not completed or significantly delayed, and care plan updates were not made to reflect new risks or interventions. Staff interviews confirmed that care plans were not consistently updated after falls, and that communication lapses contributed to the lack of timely intervention. Another resident, identified as at risk for falls upon admission, experienced eight falls without the facility identifying root causes, trends, or updating the care plan accordingly. Facility policies required comprehensive post-fall assessments, care plan reviews, and implementation of individualized interventions, but these were not followed. Staff interviews revealed inconsistent understanding and execution of fall prevention protocols, and documentation did not reflect the required monitoring or follow-up after falls.