Failure to Follow Care Plan and Provide Supervision Resulting in Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was followed and that adequate supervision was provided, resulting in multiple unwitnessed falls for a resident with significant cognitive impairment and a history of repeated falls. The resident, who had diagnoses including dementia, periprosthetic fracture, repeated falls, and major depressive disorder, experienced five falls within six months, each resulting in injury. These injuries included skin tears, bruises, lacerations, a fractured left hip, and a periprosthetic fracture around an internal prosthetic left hip joint. Despite documented care plan interventions specifying that the resident was not to be left unattended in her room or bathroom, staff failed to consistently implement these measures. Multiple incidents were documented where the resident was left alone, contrary to her care plan. In one instance, the resident was left alone in her bathroom and fell while attempting to self-transfer, resulting in a femur fracture. On another occasion, she was left alone in her room and fell, sustaining a head laceration that required sutures. In another event, a CNA left the resident in the bathroom to retrieve supplies, during which time the resident moved herself into her room and fell, resulting in facial lacerations and additional sutures. Staff interviews and documentation revealed that some staff were unaware of the resident's fall interventions, and there was a lack of consistent communication regarding care plan updates and interventions during shift reports. Observations confirmed the resident had visible injuries, including bruising and sutures on her face and forehead. Family members expressed concern about the resident being left alone despite assurances from management that this would not occur. Facility records and interviews indicated that care plan interventions were not reliably communicated or followed, contributing to the resident's repeated, injurious falls. The facility's policies required care plan updates and communication of interventions, but these were not effectively implemented for this resident.