Failure to Provide Adequate Supervision and Fall Interventions for High-Risk Resident
Penalty
Summary
A resident with a history of falls, fractures, cognitive impairment, and functional incontinence was admitted to the facility and identified as being at moderate to high risk for falls. Despite this, the resident experienced multiple falls resulting in significant injuries, including rib and wrist fractures, as well as a left femur fracture. The care plan identified several risk factors and interventions, such as keeping the bed in a low position, providing moderate assistance, and ensuring the call bell was within reach. However, the care plan failed to implement a toileting schedule, even though the resident was frequently incontinent and required increased toileting due to diuretic use. Staff interviews and documentation revealed that the resident often attempted to transfer independently, especially to use the bathroom, and did not consistently call for assistance, leading to repeated falls. The facility's documentation and staff interviews indicated that, although the resident was placed on 15-minute safety checks after multiple falls, these checks were insufficient to prevent further incidents. Staff reported that the resident was impulsive, forgetful, and would get up quickly without waiting for help, even when staff were nearby or monitoring the resident. The resident was observed ambulating without staff assistance on several occasions, and staff acknowledged that the only way to ensure the resident did not get up alone would be to provide one-to-one monitoring, which was not consistently implemented. The care plan was updated after each fall, but the lack of a scheduled toileting program persisted despite ongoing evidence that the resident's attempts to toilet independently contributed to the falls. The facility's fall and fall risk policy required staff to identify and implement interventions specific to the resident's risks and to re-evaluate and change interventions if falls continued. Despite this policy, the resident continued to fall, and the interventions in place did not adequately address the resident's needs, particularly regarding toileting assistance. The failure to implement a toileting schedule and provide adequate supervision and interventions for a resident at high risk for falls resulted in repeated accidents and serious injuries.