Failure to Provide Adequate Supervision and Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and monitoring for a resident with a significant history of falls and cognitive impairment. The resident, who resided in the memory care unit and had severe dementia, was known to wander frequently and had altercations with other residents. Despite being identified as a high fall risk with previous injuries, the care plan did not include sufficient or specific interventions to address her safety needs, wandering behavior, or fall prevention. The care plan goals were unrealistic given her cognitive status, and interventions lacked detail regarding her pain management, mobility limitations, and behavioral triggers. Multiple incidents were documented where the resident sustained injuries, including a compression fracture and a fractured hip requiring surgery. These injuries resulted from both witnessed and unwitnessed falls, as well as altercations with other residents. Progress notes and staff interviews revealed that supervision was inconsistent, and staff were often unaware of the resident's whereabouts. There was a lack of documentation regarding the direct causes of falls, the effectiveness of interventions, and whether appropriate supervision was in place at the time of each incident. Staff reported being too busy to provide adequate oversight, and 1:1 observation, when implemented, was not maintained as a long-term intervention. The facility's policies required systematic monitoring and management of residents at risk for elopement or unsafe wandering, but these were not effectively implemented for this resident. The care plan did not address specific needs such as toileting schedules, safe wandering paths, or individualized behavioral interventions. Staff interviews confirmed that interventions were limited to redirection, and additional measures such as visual cues or environmental modifications were not consistently used. The lack of adequate supervision and failure to implement effective, individualized interventions directly contributed to the resident's repeated falls and injuries.