Failure to Prevent Neglect and Address Fall Risks
Penalty
Summary
A resident with severe cognitive impairment, multiple comorbidities including schizophrenia, malnutrition, and a history of frequent falls, was not adequately monitored or provided with appropriate interventions to prevent neglect and injury. Despite being identified as a high fall risk and having a care plan that documented numerous falls, staff repeatedly failed to implement or update fall prevention interventions after each incident. The resident experienced multiple falls, some resulting in injuries that required emergency room visits, yet new or effective interventions were often not put in place, and fall risk assessments were missing after several incidents. In addition to the failure to address fall risks, staff did not consistently follow existing care plan interventions such as frequent toileting, ensuring the call light was within reach, and performing regular checks. The resident was observed on several occasions lying in bed for extended periods, saturated in urine and feces, with the call light out of reach and the door closed, making the resident not visible to staff. Staff members were seen opening the door, looking in, and leaving without providing care or cleaning the resident, even after being aware of the resident's condition. The resident remained soiled for at least five hours, and staff failed to respond to his needs despite clear evidence of incontinence and discomfort. Interviews with staff and medical professionals confirmed that the standard of care was not met, as the resident was left unattended and in an unhygienic state, and interventions to prevent falls and address incontinence were not followed. The facility's own policies defined such actions as neglect, including inadequate provision of care, poor hygiene, and leaving someone unattended who needs supervision. The repeated lack of appropriate response and disregard for the resident's care, comfort, and safety led to the identification of neglect and the declaration of Immediate Jeopardy.
Removal Plan
- R2 was provided with 1:1 sitter.
- DON/ADON completed skin assessment on R2 with no negative outcomes noted.
- Administrator, DON & ADON were in-serviced by the RNC on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Administrator in-serviced all department heads on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Department managers in-serviced department staff members on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Staff will not work until in-serviced on the Abuse Prevention Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- DON/ADON/Department Manager will in-service any future agency employees on the Abuse Prevention Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- The DON/ADON/Licensed staff completed skin assessment on residents requiring incontinent care.
- A quality assurance tool was implemented: DON/ADON/CNA Supervisor will conduct audits on residents requiring incontinent care and completed in timely manner.
- A quality assurance tool was implemented for SSD (Social Service Director) or designee to conduct resident interviews to ensure there are no concerns related to Abuse/Neglect.
- The DON/ADON will complete audit review during daily morning clinical meeting to ensure compliance.
- Audit tool will also include review of new/re-admit fall risk assessments for resident high risk to ensure prevention measure are in place.
- Root cause analysis completed for neglect related to coordination of care provided to residents.