Failure to Prevent Falls and Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that fall prevention interventions were in place and adequate supervision was provided for two residents identified as high risk for falls. One resident with a history of falls, severe cognitive impairment, and multiple comorbidities experienced several falls within the facility. Despite being care planned for interventions such as placement near the nurse's station and use of a bed alarm, the resident was found on the hallway floor after an unwitnessed fall. Staff interviews revealed that the bed alarm was not functioning properly due to a low battery, which had been reported but not addressed, resulting in the alarm being too faint to alert staff. The resident sustained a severe intracranial subdural hematoma and was hospitalized, ultimately expiring due to the injuries sustained from the fall. Another resident, also at high risk for falls due to impaired mobility and a history of falling, was found on the floor in a hallway area not visible from the nurse's station. Staff interviews indicated that this area was a known blind spot and not considered safe for unsupervised residents. The fall was unwitnessed, and it was reported that another resident had pulled the wheelchair from under the resident, causing the fall. The resident was sent to the hospital and diagnosed with a subdural hemorrhage. The care plan for this resident included the use of a chair alarm to alert staff of independent transfers, but the incident occurred in an area where staff could not provide adequate supervision. Facility policies and job descriptions reviewed in the report emphasized the responsibility of staff to ensure resident safety, maintain functioning equipment, and provide supervision according to individualized care plans. However, the failure to maintain equipment such as bed alarms and to supervise residents in high-risk areas directly contributed to the falls and subsequent injuries. The documented deficiencies were based on staff interviews, record reviews, and hospital records, which detailed the sequence of events and the lack of effective interventions at the time of the incidents.