Failure to Provide Adequate Supervision and Safety Devices to Prevent Resident Falls
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents. The resident, who had diagnoses including dementia, hypertension, and anxiety, was assessed as having severe cognitive impairment and was dependent on staff for several activities of daily living. The resident had a history of falls and was identified as being at risk for further falls, with a care plan in place that included specific interventions such as the use of Dycem on the wheelchair cushion to prevent slipping. Despite these interventions being documented in the care plan and Kardex, observations on multiple occasions revealed that Dycem was not present on the resident's wheelchair cushion as required. Staff interviews confirmed a lack of awareness regarding the presence of Dycem, and direct observation by the surveyor on two separate days confirmed its absence. The resident was observed propelling herself in the wheelchair and participating in daily activities without the prescribed safety device in place. Additionally, after the resident experienced a fall, the facility did not conduct a thorough investigation. The incident report lacked staff statements, did not identify a root cause, and did not provide evidence that prior interventions were in place to prevent the fall. The investigation was incomplete, and there was no documentation explaining why the Dycem was not in use according to the care plan at the time of the fall.