Failure to Prevent Accident Hazards and Ensure Timely Response to Falls
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision or assistance devices to prevent accidents for a resident with a history of frequent falls and severe cognitive impairment. The resident, who had diagnoses including repeated falls, impulse disorder, cerebral infarction, muscle weakness, unspecified lack of coordination, bipolar disorder, and chronic kidney disease requiring dialysis, was allowed to self-propel in a wheelchair outside the facility without supervision. The area outside included hazards such as broken pavement, exposed dirt and rocks, and was adjacent to a busy highway. Staff and administration were aware that the resident was allowed outside unsupervised, and there were no care plan interventions specifying the type or frequency of supervision required for outdoor activities, despite the resident's high fall risk and severe cognitive impairment as indicated by a BIMS score of 7. Multiple staff interviews confirmed that the resident was permitted to go outside alone, and that staff would intermittently check on him, with intervals ranging from every 10 minutes to every hour or two. Observations documented the resident navigating hazardous outdoor areas without staff present. Staff acknowledged that the resident had a history of unwitnessed falls both inside and outside the facility, and that he was difficult to redirect and lacked safety awareness. Despite these known risks, the care plan did not include specific interventions for outdoor supervision, and staff relied on the resident's ability to follow instructions, even though his cognitive status was severely impaired. Additionally, the facility failed to ensure prompt and appropriate response to an unwitnessed fall. On one occasion, the resident was found on the floor in his room by a staff member and a visitor, who reported a delay in nursing response. The fall was not documented, nor were notifications made to the DON, physician, or resident representative. Staff interviews revealed confusion about whether the resident's behavior of placing himself on the floor should be treated as a fall, leading to inconsistent documentation and reporting. The lack of immediate assessment and failure to follow facility policy for fall response and documentation placed the resident at risk for harm.