Failure to Provide Adequate Supervision and Post-Fall Review
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision for three residents. One resident, who was severely cognitively impaired and required a 1:1 sitter due to aggressive behaviors and a history of losing balance, was left unsupervised on the patio while the assigned sitter was inside the facility using a personal phone for four minutes. The sitter acknowledged being distracted by personal emails and not observing the resident as required by facility policy, which prohibits personal phone use during supervision duties. Additionally, two other residents with significant cognitive impairments and histories of falls experienced multiple unwitnessed and witnessed falls. Despite these incidents, the facility did not conduct required interdisciplinary team (IDT) meetings after each fall, as outlined in their policies. Record reviews confirmed that no post-fall IDT meetings were held for these residents following their falls in July and August, even though the facility's procedures mandate such reviews within 24 hours to analyze causes and update care plans. The lack of supervision and failure to follow post-fall protocols were confirmed through staff interviews, record reviews, and direct observation. The Director of Nursing and other staff acknowledged that the facility's policies require constant supervision for high-risk residents and timely IDT meetings after falls, but these procedures were not followed for the residents in question.