Failure to Prevent Accidents Due to Inadequate Supervision and Equipment Maintenance
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent avoidable accidents for three residents, all of whom were at high risk for falls. For one resident with end-stage heart failure, chronic kidney disease, and on hospice care, staff did not implement care-planned hourly safety rounds, did not ensure functioning motion sensors, and failed to maintain a working call light system. On the night of the incident, nursing staff left the unit unattended for extended breaks, during which the resident experienced an unwitnessed fall and was found deceased on the floor with the call light detached. There was no evidence of hourly rounding or toileting hygiene being completed as required, and staff were unaware of the resident's need for increased supervision. Documentation of care and the circumstances surrounding the resident's death was also lacking. Another resident with dementia, muscle weakness, and other comorbidities, who was also at high risk for falls, did not receive the required hourly checks or toileting assistance as outlined in their care plan. The motion sensor in the resident's room was not properly positioned to detect movement from all sides of the bed, resulting in a fall that was not detected by the alarm system. Staff interviews revealed a lack of awareness regarding the resident's specific fall interventions and care plan requirements, and documentation of overnight care was missing or incomplete. A third resident with Parkinson's disease and a history of multiple unwitnessed falls had care plan interventions for frequent checks and motion sensor use, but these interventions were not consistently implemented or documented. The resident experienced multiple unwitnessed falls, including one that resulted in a hip fracture and hospitalization. Facility leadership confirmed that care plans were not updated after falls, incident reports were not completed, and there was no documentation or monitoring of the effectiveness of hourly checks. Staff interviews consistently revealed a lack of awareness of which residents required increased supervision, and the facility lacked policies for supervision, call light maintenance, and response to untimely deaths.