Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent accident hazards for a resident with significant cognitive impairment and a history of multiple falls. The resident, who had diagnoses including dementia and was non-ambulatory following an amputation, was admitted with impaired cognitive status, disorientation, and decreased safety awareness. Despite these risk factors, the initial fall risk assessment categorized the resident as low risk, and interventions were limited to basic fall precautions such as keeping the bed in the lowest position, ensuring the call bell was within reach, and maintaining a clutter-free environment. Over the course of the resident's stay, there were at least seven documented falls, many of which were unwitnessed and occurred despite repeated updates to the resident's care plan. Interventions were added incrementally after each fall, such as bolsters to the bed, padding, frequent toileting, and eventually a chair alarm. However, the resident continued to exhibit impulsive behaviors, attempts to self-transfer, and was only re-directable for short periods. Staff interviews revealed that the facility did not implement 1:1 supervision or 15-minute safety checks, citing staffing limitations. The resident's family was approached about hiring a private nurse aide for supervision, but this was not consistently in place, and at times the aide left or was not replaced. Throughout the period in question, staff and supervisors acknowledged the resident's high fall risk and behavioral challenges, but the facility was unable to provide the level of supervision required to prevent further incidents. The resident continued to experience falls, including one resulting in a stable L1 spinal fracture, and staff reported that close observation protocols were not documented or implemented. The facility's fall prevention program required individualized care based on risk, but the actions taken were insufficient to address the resident's ongoing needs, leading to repeated accidents and injury.