Failure to Implement Fall Prevention Measures and Supervision
Penalty
Summary
The facility failed to implement fall prevention measures as indicated in the care plans for three residents identified as high risk for falls. For one resident with dementia and a history of falls, the care plan required the use of bed/chair alarms and placement in the dining room during the day for supervision. However, the resident experienced an unwitnessed fall resulting in multiple fractures while left unsupervised in their room, despite the presence of a family member who was not educated on supervision requirements. Documentation did not show that the family member was instructed not to leave the resident alone or when to notify staff, and there was no record of staff providing such education. Another resident with cognitive impairment and a history of femur fracture was care planned for a bed alarm and increased supervision, including being up in the dining room in the morning. The resident was observed in bed with a bed alarm that was not functioning because it was turned off. Staff were unaware the alarm was not working, and the resident's care plan interventions were not consistently implemented, as the resident was not always monitored in the dining room as intended. The facility lacked a policy for bed alarms, and post-fall interventions were not clearly documented or followed. A third resident with dementia and multiple comorbidities, including a history of falls, sustained a significant injury after an unwitnessed fall. The resident's care plan included bed/chair alarms and supervision, but the fall occurred when the resident was left alone in the room. The facility's fall prevention policies required close supervision and reevaluation of interventions for high-risk residents, but these were not consistently applied. Staff interviews confirmed that care plan interventions were not always followed, and deviations were not documented as required.