Failure to Implement Supervision Interventions for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when a cognitively impaired resident with a history of restlessness, impulsivity, and multiple prior falls sustained a non-displaced fracture of the left clavicle. The resident was known to be at high risk for falls, as indicated by repeated high scores on the Morse Fall Scale and documented incidents of previous falls resulting in injuries such as skin tears and hematomas. The resident's care plan included specific interventions, such as transferring the resident to a recliner chair at the nursing station for increased supervision during periods of restlessness at night. On the night in question, the resident exhibited restlessness from approximately 11:00 PM until 4:00 AM, as reported by the CNA assigned to the shift. However, the intervention to transfer the resident to the recliner chair at the nursing station was not implemented, despite the resident not refusing the transfer. There was also a lack of documentation regarding the resident's restlessness in the plan of care or progress notes, and the nurse on duty was not informed of the resident's behavior. The following morning, the resident was found to be guarding their left arm and grimacing in pain, which led to the discovery of the clavicle fracture after an x-ray was performed. Interviews with staff revealed inconsistencies in the reporting and documentation of the resident's behavior during the night. The CNA stated she was aware of the care plan intervention but did not carry it out or properly document the resident's restlessness. The nurse on duty confirmed that, had she been informed, she would have taken additional steps to address the resident's needs. The failure to implement the care plan intervention and provide adequate supervision during a period of increased restlessness directly contributed to the resident's injury.