Failure to Provide Adequate Supervision and Safety Measures to Prevent Falls and Choking
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. One resident with Alzheimer’s disease, severe cognitive impairment (BIMS score of 5), wandering behavior, and a documented fall risk score of 10 had a care plan intervention for the bed to be in the lowest position. Despite this, on the day of the incident, the resident’s bed was found at about waist height after the resident had been seen resting in bed in the lowest position 20–30 minutes earlier. The resident was later found walking in the hallway with a walker, bleeding from the head, face, nose, and mouth, and staff documentation and the fall protocol checklist indicated that the bed was high and that the resident likely raised the bed using the remote, which was found next to the side rail. The same resident had prior documentation of restlessness, combative behaviors, and wandering into other residents’ rooms on the day of the fall. Nursing notes indicated the resident was being monitored for these behaviors and that she was easily redirected and cooperative, but the facility’s fall investigation and self-report did not address why adequate supervision was not provided at the time of the fall, despite these behaviors. The surveyor noted that the fall intervention of a low bed was not in place at the time of the fall and that no additional information was provided by facility leadership explaining the lack of supervision and the absence of the low-bed intervention when the fall occurred. A second deficiency involved another resident with chronic respiratory failure, tracheostomy status, laryngeal hypoplasia, epilepsy, obesity, functional quadriplegia, type 2 diabetes, and dysphagia, who had speech therapy recommendations and a care plan requiring a mechanical soft diet, supervision during meals, and use of a Passy Muir speaking valve (PMSV) during all PO intake. The facility’s own Meal Supervision and Assistance policy required adequate supervision during meals based on assessed needs and identified risks. During one observation, the resident was found in bed with a lunch plate on the lap, eating independently and having consumed at least half of the meal before a unit manager entered, placed a cap on the trach, and stated she would stay because the resident needed supervision when eating. On another observation, the resident was lying in bed with the head of bed elevated, the lunch tray in front, the PMSV not in place, and no staff entering the room to supervise for 27 minutes, despite the documented need for supervision with meals and PMSV use during all PO intake.
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