Failure to Consistently Supervise High-Risk Resident to Prevent Falls
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement fall-prevention interventions and adequate supervision for a resident with a history of traumatic brain injury, dementia with agitation, and multiple prior falls. The resident was admitted with significant cognitive impairment, as evidenced by an incomplete BIMS due to poor cognition, and was assessed as high risk for falls with a fall risk score of 19. The quarterly MDS documented that the resident was dependent on staff for transfers and had experienced two or more falls with no or minor injury since the prior assessment. The resident’s care plan, updated after multiple falls and a hip fracture, identified the resident as high risk for falls and included interventions such as close supervision when in the wheelchair/Broda chair, frequent monitoring when in bed, and getting the resident out of bed to a Broda chair or common area when awake at night. Despite these identified risks and care-planned interventions, facility documentation and staff practices did not reflect consistent monitoring or supervision. Review of the MARs, TARs, and CNA documentation from October through December showed no entries indicating that the resident was being monitored to prevent falls, and monitoring was not listed as a fall intervention in those records. Incident/accident reports revealed a pattern of unwitnessed and unsupervised falls on numerous occasions, often in the hallway or near the nurse’s station, with the resident unable to explain how the falls occurred. These falls included multiple events from the resident’s wheelchair or Broda chair and culminated in a fall resulting in a left hip fracture, after which the resident was hospitalized and later returned to the facility. Direct observations by surveyors further demonstrated lapses in supervision inconsistent with the care plan and staff expectations. On several observed occasions, the resident was in a Broda chair in hallways, common areas, and even stuck in a staff office, propelling himself and at times attempting to stand, without staff present to monitor him. Staff interviews confirmed that the resident was known to be at high risk for falls, was impulsive, and was supposed to remain within line of sight of staff at all times when up in the Broda chair. The DON, Administrator, Regional VP of Operations, and Regional Nurse all confirmed that the resident was expected to be in line of sight when up in the Broda chair due to his high fall risk. The facility’s fall prevention policy required assessment of fall risks and implementation of preventative measures when risks were identified, but the repeated unwitnessed falls and lack of documented monitoring showed that these measures were not consistently carried out, resulting in a fall with major injury (hip fracture).
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