Failure to Provide Adequate Supervision for Resident with Recurrent Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent potential injury for a resident with a history of falls and multiple medical conditions, including Parkinson's with dementia, polyosteoarthritis, epilepsy, anemia, and mild cognitive impairment. The resident was dependent on staff for activities of daily living, exhibited impulsivity, and was noted to wander and sit on the floor. Despite these risk factors, the care plan did not include interventions addressing the resident's wandering behavior or the need for increased supervision. Over a five-month period, the resident experienced 20 falls in their room, 19 of which were unwitnessed, as well as additional unwitnessed falls in the dining room and hallway. Observation revealed the resident self-propelling in a wheelchair without shoes and with a visible bruise on the right foot and toes. Incident reports and interviews confirmed ongoing concerns about the frequency of falls and the lack of effective supervision or interventions to address wandering. The unit manager acknowledged the resident's wandering and history of unwitnessed falls, but the care plan remained insufficient in addressing these specific supervision needs.