Failure to Adequately Supervise High-Risk Resident Resulting in Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement effective fall-prevention interventions for a resident with a known high risk for falls and cognitive impairment. The resident was admitted with diagnoses including abnormalities of gait and mobility, age-related physical debility, osteoarthritis, a lumbar compression fracture, and vascular dementia. The admission MDS documented that walking at least 10 feet in a room was not attempted due to medical or safety concerns, that the resident used a walker and wheelchair, had lower extremity range-of-motion limitations, and had a prior fall before admission. The resident’s BIMS score was 8, indicating moderately impaired mental status with inability to recall the correct year, month, and day of the week. The facility’s own assessments repeatedly identified the resident as being at high risk for falls, with fall risk assessment scores of 28, 28, and 36 on three separate dates. Interdisciplinary team notes documented multiple falls: staff heard screaming and found the resident on the floor on one occasion; on another, a staff member heard the resident calling for help and found the resident on the floor after an unwitnessed fall in which the resident reported striking her head. Despite these repeated unwitnessed falls and the resident’s ongoing behaviors of trying to get out of bed to ambulate with agitation, aggression, and hallucinations, the fall care plans dated after these events were not updated with new or enhanced interventions beyond general measures such as keeping the bed low and call light within reach. On the date of the cited incident, a family member of another resident observed the high-risk resident ambulating from her bed toward the room doorway, losing balance, and falling forward to the ground. Staff were not present at the time of the fall and were summoned by the family member. The resident was found on the floor with a laceration on the left frontal forehead and uncontrolled bleeding and was subsequently transferred to the hospital, where a subarachnoid hemorrhage was diagnosed. Interviews with staff indicated that the resident frequently attempted to get out of bed without assistance, that hourly safety checks and reminders to call for help were relied upon, and that the facility did not provide one-on-one sitters for fall-risk residents, instead discussing such arrangements with families. The facility’s fall policy required staff to identify interventions related to specific risks and causes based on evaluations and data, but the care plans were not revised with additional interventions after the repeated unwitnessed falls and escalating fall risk behaviors.
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