Failure to Revise Care Plan and Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to revise and implement care plan interventions to prevent falls and provide adequate supervision for a resident identified as high risk for falls. The resident had multiple diagnoses, including metabolic encephalopathy, diabetes, lack of coordination, cognitive communication deficit, muscle wasting, spinal stenosis, Parkinson's disease, a history of falls, and altered mental status. Despite these risk factors, the resident experienced frequent episodes of agitation, restlessness, and behaviors that could result in falls, as documented in progress notes and observed by staff. On several occasions, the resident was observed in common areas, such as the dining room and hallways, without staff supervision. The resident repeatedly attempted to stand, walk, or manipulate wheelchair footrests, often requiring redirection. In the absence of staff, another resident took it upon herself to watch over and redirect the resident, stating that there was not enough staff to provide supervision. Staff interviews confirmed that one-to-one care had been discontinued due to staffing shortages, and that supervision was provided only when possible. The resident's family member reported numerous falls since admission and was unaware of any new interventions to prevent further incidents. Review of the resident's care plan revealed that, despite multiple falls, interventions were not updated to address supervision, monitoring, or specific fall risk behaviors. The care plan did not reflect changes or personalized preventative measures after each fall, contrary to the facility's own Fall Prevention Program policy, which requires care plans to be revised with each incident. Facility leadership acknowledged that the resident was not on safety monitoring and that care plan interventions had not been reviewed or adjusted as required.