Failure to Maintain Safe Environment and Supervision Resulting in Repeat Resident Falls
Penalty
Summary
The facility failed to maintain a safe environment, provide adequate supervision, and implement necessary assistive interventions for three residents reviewed for falls. Each of these residents was identified as high risk for falls due to severe cognitive impairment and dependence on staff for activities of daily living, including toileting. Despite documented histories of falls and related injuries, care plans for these residents were not initiated or updated in a timely manner, and essential interventions such as toileting schedules and transfer status were not communicated to staff or included in the electronic Kardex. Staff interviews revealed a lack of awareness regarding residents' care needs and interventions, with several CNAs and nurses stating they did not know where to find updated information or were unaware of specific care plans in place for fall prevention. One resident was admitted following a fall that resulted in a subdural hematoma and subarachnoid hemorrhage, yet did not have fall interventions included in the care plan upon admission. This resident experienced multiple subsequent falls within the facility, including one resulting in a head laceration and another subdural hematoma, with documentation gaps regarding toileting and transfer assistance. Staff reported confusion about the resident's care needs, and the care plan was not updated to reflect necessary interventions until well after the incidents occurred. Another resident, also severely cognitively impaired and on anticoagulant therapy, experienced unwitnessed falls, including one where the resident slipped in urine and another resulting in a laceration requiring sutures. The fall care plan for this resident was not created until after the initial fall, and the Kardex did not reflect fall interventions. A third resident, with repeated falls documented over several months, did not have toileting tasks or new safety interventions added to the care plan or Kardex until long after multiple incidents. Staff interviews indicated that interventions such as placing the resident in a recliner to prevent sliding from a wheelchair were not documented in the care plan. The MDS nurse acknowledged delays in updating care plans due to workload and staffing issues, and the DON stated she was not aware that care plans were not being updated. Throughout the report, there is consistent evidence of inadequate communication, lack of timely care plan updates, and insufficient staff training regarding fall prevention and resident care needs.