Failure to Prevent Falls Due to Inadequate Supervision and Assistance
Penalty
Summary
The facility failed to ensure a safe environment and provide adequate supervision and assistance to prevent falls for two residents, resulting in significant injuries. One resident, who was ventilator-dependent, quadriplegic, morbidly obese, and under hospice care, required total assistance for all activities of daily living. During incontinence care, this resident was being assisted by only one certified nursing assistant (CNA), despite being a total assist and unable to help or follow commands. The CNA attempted to provide care alone, during which the resident fell from the bed, sustaining comminuted fractures to the left tibia and fibula. The resident was transferred to the hospital, underwent surgery, and subsequently expired following a cardiac arrest. Interviews with staff revealed inconsistent understanding of the required level of assistance, and there was no documentation supporting the use of one-person assist for this resident during such care. Another resident with severe cognitive impairment, as indicated by a low BIMS score, fell in the activity room immediately after participating in a group activity. The resident attempted to ambulate independently, tripped over a box or ornament, and sustained a laceration requiring sutures. Staff interviews indicated that supervision was not maintained in the activity room after the activity ended, and there was no clear policy or procedure for monitoring high-risk residents during or after activities. The activity aides were either escorting other residents or occupied in the kitchen at the time of the fall, leaving the cognitively impaired resident unsupervised. The facility's policies on fall management and activity supervision were reviewed, but staff were unable to provide documentation or guidance specific to supervision requirements in the activity room for high-risk residents. The lack of clear protocols and inconsistent staff understanding contributed to the failure to implement appropriate fall prevention interventions and ensure adequate assistance and supervision during high-risk care situations.