Failure to Implement Fall-Prevention Interventions and Provide Adequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implementation of appropriate fall-prevention interventions for three residents, despite identified fall risks and existing care plan directives. One resident with weakness, malaise, orthostatic hypotension, and moderate cognitive impairment (BIMS 12/15) was care planned as high risk for falls with specific interventions including not leaving the resident alone in the bathroom and ensuring appropriate footwear during ambulation. On the date of the incident, a CNA ambulated this resident to the bathroom with a gait belt; the resident pulled down her own pants and told the CNA he could leave. After the CNA began to close the door, he heard a loud noise and found the resident on the bathroom floor, with the RN later documenting that the resident reported hitting her head and having right hip pain. The record notes the resident did not have proper footwear on to ambulate, and the care plan intervention to not leave the resident alone in the bathroom was not followed. Another resident with neurocognitive disorder with Lewy Bodies, major depressive disorder, bipolar disorder, PTSD, repeated falls, and severe cognitive impairment (BIMS 5/15) had been care planned as high risk for falls, with interventions including keeping frequently used items within reach and providing 1:1 supervision due to poor safety awareness. While on 1:1 observation, this resident slipped off the bed while reaching for a phone, as documented by a CNA witness statement and an incident report. Later observation showed the resident lying half on and half off the bed, with the tray table about 12 inches from the bed and no phone on the tray table, indicating that frequently used items were not within reach as specified in the care plan. A third resident with multiple medical conditions including metastatic cancer, squamous cell carcinoma, DM II, CKD stage 4, BPH, and essential tremor was assessed as moderately at risk for falls and later documented by therapy as requiring assistance of one person to walk with a walker. The care plan identified the resident as high risk for falls related to poor safety awareness, with interventions such as ensuring all necessities were within reach and encouraging use of proper ambulatory assistive devices. A fall report indicated that staff found this resident on the floor next to the bed after he attempted to get up to go to the bathroom without his walker, which had been left in the bathroom. The documentation noted that the resident sometimes ambulated with a walker without assistance, but at the time of the fall the walker, identified as a necessary assistive device, was not within reach, contrary to the care plan intervention. As a result of these failures, one resident sustained a right hip fracture requiring hospitalization and surgical intervention.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.