Inadequate Staffing and Supervision Leading to Multiple Falls
Penalty
Summary
The facility failed to provide sufficient staffing and supervision to prevent falls for a high-risk resident. The resident was admitted with multiple diagnoses including a displaced subtrochanteric fracture of the right femur, anemia, cerebral ischemia, urinary retention, Alzheimer's disease, dementia, prior falls with fractures, and adult failure to thrive. A fall risk assessment showed a high fall risk score of 22, and the care plan identified risk for falls related to impaired mobility, medication side effects, and history of falls, with interventions such as keeping the call light and personal items within reach, providing nonskid footwear, assisting with transfers, and therapy evaluation. Additional interventions later included use of dycem on the wheelchair and having the resident in a common area after family left in the evening. Despite these identified risks and interventions, the resident experienced multiple falls within a short period. On three separate occasions, the resident was found on the floor after attempting to self-transfer or falling from the wheelchair, including one fall in the hallway where the resident hit his head and was sent to the ER, and another fall resulting in painful and limited range of motion in the lower extremity. Post-fall investigations documented that the resident became anxious after family left and attempted to self-transfer, and that the resident was to be kept at the nurse’s station or in a common area for supervision. However, the medical record showed the resident was not assessed after the falls for further injury, including vital signs. Staffing schedules for the relevant dates showed three CNAs and two nurses on the night shift for 47–48 residents, with each nurse responsible for two hallways and each CNA for one hallway plus additional rooms. A CNA reported that with the usual staffing pattern, residents requiring increased supervision could not be adequately supervised, and the resident’s family reported difficulty finding CNAs or nurses responsible for the resident’s care due to staff covering multiple hallways. The administrator acknowledged an issue with falls that had been taken to QAPI and a pattern to when falls occurred.
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