Failure to Prevent Falls and Maintain Safe Environment for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and maintain a hazard-free environment for three residents at risk for falls. One resident with a history of metabolic encephalopathy, hemiplegia, and hemiparesis following a stroke was left unsupervised in the bathroom by an RN, despite care plan interventions requiring frequent visual checks due to poor decision-making and inability to use the call light. This resident subsequently fell, sustaining a 4 cm hematoma on the right forehead and was diagnosed with a non-traumatic intracranial hemorrhage after transfer to an acute care hospital. Another resident, also with hemiplegia and hemiparesis following a cerebral infarction and classified as high risk for falls, was observed with their bed in a high position, contrary to care plan instructions and staff knowledge that the bed should be kept in the lowest position to prevent falls. The resident was not informed by staff about the risks associated with the bed's position and was not reminded to keep it low, despite documentation in nursing progress notes indicating this requirement. A third resident, with diagnoses including hemiplegia, hemiparesis, metabolic encephalopathy, and dementia, required total dependence for mobility and was at high risk for falls. This resident was found on the floor with the call light out of reach while the assigned CNA was on break and had not endorsed coverage to another staff member. The care plan required the call light to be within reach and frequent visual checks, but these interventions were not followed, and the resident was not monitored during the CNA's absence.