Failure to Prevent Falls Due to Inadequate Supervision and Care Plan Implementation
Penalty
Summary
The facility failed to prevent falls for two residents who were identified as being at high risk for accidents. One resident with vascular dementia, muscle weakness, and significant cognitive impairment experienced multiple falls after a decline in health and functional abilities. Despite assessments indicating the resident was dependent for activities of daily living (ADLs), including dressing, the care plan continued to encourage the resident to participate in dressing. This led to a fall when the resident, while being assisted by one staff member, became unsteady and lost balance during care. The care plan was not updated in a timely manner to reflect the resident's increased dependency and fall risk. Another resident with vascular dementia, mobility issues, and a history of repeated falls was also at high risk for accidents. This resident, who used a wheelchair and was dependent for mobility and transfers, experienced multiple falls, including one unwitnessed event. The care plan included interventions for fall prevention, such as providing sensory activities if the resident refused to go to bed after dinner. However, after refusing to go to bed, the resident attempted to transfer independently, resulting in a fall. The intervention to provide a sensory activity or busy box was not in place at the time of the incident, contributing to the fall. Record reviews, staff interviews, and observations confirmed that the facility did not consistently implement or update individualized care plan interventions to address the residents' changing needs and fall risks. The facility's policy required resident-centered fall prevention plans and timely care plan updates after falls, but these measures were not adequately followed for the residents involved.