Failure to Provide Adequate Supervision for Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent accidents for a resident with a known history of falls and cognitive impairment. The resident had multiple risk factors, including dementia, unsteady gait, a recent fracture, and required significant assistance with mobility and toileting. Despite these risks, the primary intervention implemented was the use of chair and bed alarms, which were intended to alert staff when the resident attempted to stand. However, the care plan did not specify any staff supervision interventions tailored to the resident's needs, and staff interviews confirmed that supervision was not consistently provided beyond reliance on alarms. On the day of the incident, the resident was found on the bathroom floor after a fall, which resulted in a left hip fracture. Investigation revealed that the chair alarm, which was supposed to alert staff if the resident attempted to stand, had been turned off by staff during a previous transfer and was not reactivated. Staff relied heavily on alarms as the main intervention for fall prevention and did not provide direct supervision or ensure the alarm was always active. The resident was left unsupervised, and staff only discovered the fall when passing by the room for unrelated reasons. Interviews with various staff members, including medication assistants, nursing assistants, and the DON, indicated a lack of understanding regarding the need for supervision beyond the use of alarms. Staff described the process of responding to alarms but did not mention any protocols for direct supervision or individualized monitoring based on the resident's assessed needs. The facility's fall prevention policy emphasized a team approach and individualized care planning, but in practice, interventions were limited to alarm use without adequate supervision, contributing to the resident's fall and injury.