Failure to Prevent Accidents and Ensure Adequate Supervision for Residents at Risk of Falls
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure a safe environment free from accident hazards and to provide adequate supervision to prevent accidents for two residents with significant fall risks and physical impairments. One resident, admitted with multiple diagnoses including infection due to a knee prosthesis, bacteremia, myasthenia gravis, essential tremors, and gait abnormalities, was dependent on staff for transfers and had impaired range of motion. Despite these risks, the resident experienced a fall while attempting to transfer from a recliner to bed. Documentation revealed that staff were aware the resident needed assistance and instructed the resident to wait, but upon returning, found the resident on one knee at the bedside. The incident was not fully investigated, as required by facility policy, with no comprehensive documentation, staff statements, or root cause analysis completed. Progress notes did not reflect the fall, and there was no evidence of a formal review during clinical meetings. Another resident, assessed as severely cognitively impaired and at high risk for falls, required extensive assistance with activities of daily living and had a history of multiple falls. The resident's care plan included interventions such as keeping a call light and bell within reach, frequent rounding, and environmental modifications to reduce fall risk. However, multiple observations showed the resident's bell was consistently out of reach, and at times, the call light was not accessible. Staff confirmed the call light was broken and a work order was supposedly placed, but the Environmental Service Director reported no such work order had been submitted. The resident was left without access to a call light or bell for over an hour, contrary to the care plan interventions. These events demonstrate lapses in both the implementation of individualized fall prevention interventions and the facility's investigative processes following incidents. The lack of thorough documentation, failure to ensure assistive devices were within reach, and incomplete post-fall investigation contributed to the deficiencies identified for both residents.