Failure to Provide Adequate Supervision and Fall Risk Reassessment Resulting in Harm
Penalty
Summary
The facility failed to ensure adequate supervision and timely reassessment of fall risk for two residents with a history of repeated falls, resulting in significant injuries. For one resident with moderate cognitive impairment and a high fall risk score, there were four unwitnessed falls over five months, culminating in a fall that caused a head laceration, closed traumatic eye injury, right humerus fracture, and right femoral fracture. Despite an interdisciplinary team (IDT) discussion recommending increased staff monitoring, there was no documentation that this intervention was implemented. Additionally, post-fall assessments and neurological checks were either incomplete or missing, and care plans were not updated to reflect the resident's ongoing fall risk or new interventions after each incident. Another resident with severe cognitive impairment and a high fall risk score experienced multiple falls with injuries, including a recent incident resulting in a subdural hematoma, traumatic subarachnoid hemorrhage, hypotension, and complex facial lacerations. The facility did not conduct updated fall risk assessments after the initial assessment, and post-fall and neurological assessments were inconsistently completed. There was no evidence that the IDT met or revised the care plan in response to the resident's increased fall frequency or injuries. Observations revealed that environmental safety measures, such as fall mats, were not present, and staff were unaware of the origins of some injuries. Interviews with facility staff, including the DON and Medical Director, confirmed that falls and injuries occurred and that standard protocols for assessment and intervention were not consistently followed. The facility's policy required evaluation, implementation, and monitoring of interventions to prevent accidents, but documentation and practice did not align with these requirements. The lack of reassessment, incomplete documentation, and failure to update care plans contributed to the residents' repeated falls and resulting harm.