Failure to Prevent Accidents and Inadequate Fall Risk Management
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. For one resident with a history of falls, dementia, and impaired cognition, a physician order required the use of a bed sensor pad alarm for safety. However, during observation, the resident was able to get up from bed and walk unassisted to the bathroom without the alarm sounding or staff responding. The resident reported multiple prior falls and stated she was not supposed to walk alone, but did so because staff did not always respond promptly when she needed to use the toilet. Another resident, admitted with diagnoses including metabolic encephalopathy and seizures, experienced multiple falls resulting in head lacerations. Documentation showed that after each fall, the facility's licensed nursing staff either failed to conduct a fall risk assessment or completed it inaccurately, incorrectly assessing the resident as low risk despite repeated incidents. The Director of Nursing confirmed that required fall risk evaluations were not completed or were inaccurate, and acknowledged that this increased the likelihood of further falls. Additionally, the facility's Interdisciplinary Team did not conduct comprehensive root cause analyses following the resident's falls, nor did they update the resident's care plan interventions to address the ongoing risk. The care plan was not reviewed or revised after repeated falls, and the team did not consider the resident's diagnoses as contributing factors. The facility's own policy required post-fall management, including care plan updates and multidisciplinary review, but these steps were not followed after the incidents.