Failure to Complete Fall Risk Assessments and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that each resident received adequate supervision and assistive devices to prevent accidents. Two residents were admitted without completed fall risk assessments, as key sections such as gait/balance, medications, and vision were left unmarked. Baseline care plans for both residents were also not completed, and staff were not fully aware of the residents' needs for assistive devices or the level of supervision required. In one case, a resident with multiple diagnoses, including heart failure and hypoxemia, experienced a fall resulting in significant injuries, including rib and clavicle fractures. The fall risk assessment for this resident was incomplete, and there was confusion among staff regarding the use of assistive devices, with the resident using furniture for balance and a cane brought from home rather than a facility-provided walker. Another resident, admitted for hospice respite care with diagnoses including pancreatic cancer and malnutrition, also had an incomplete fall risk assessment and no baseline care plan. This resident was found on the bathroom floor with a head laceration after being left alone on the toilet by a CNA, despite requiring moderate assistance for transfers. The CNA had instructed the resident to use the emergency call light for assistance, but the resident experienced a syncopal episode and was transported to the emergency room. Staff interviews revealed inconsistent understanding of the residents' fall risks and the required level of supervision, with some staff believing that the presence of family or the resident's cognitive status reduced the need for fall precautions. Further review indicated that post-fall protocols, such as neurological checks and reporting, were not consistently followed. In one instance, an agency nurse failed to conduct a neuro check or post-fall evaluation and did not communicate the fall to the next shift. Facility policy required identification and documentation of fall risk factors and communication with residents and families, but these steps were not completed for the affected residents. The deficiencies led to the identification of Immediate Jeopardy due to the lack of timely and complete fall risk assessments, incomplete care plans, and inadequate supervision and follow-up after falls.