Failure to Implement Adequate Fall Risk Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implementation of fall risk interventions for a resident with known cognitive impairment, behavioral issues, and a history of falls. The resident was admitted with dementia, anxiety, and a recent fractured thigh bone, and assessments documented that the resident was at risk for wandering, had multiple prior falls, poor safety awareness, dizziness, communication problems, incontinence, and behaviors such as frustration, aggression, and ambulating without assistance into others’ rooms. The care plan identified the resident as at risk for falls due to a recent fracture and balance problems, and specified the need for one staff to assist with transfers and non‑pharmaceutical interventions such as not forcing or rushing care and providing one‑on‑one and decreased overstimulation as needed. Behavior documentation in early January showed episodes of agitation, threats toward others, pacing without staff assistance, and unsuccessful interventions to address these behaviors. On the day of the incident, the resident experienced two falls. In the first, the resident was last seen in bed, then stood up and held the windowsill without assistance before falling onto a floor mat and hitting an elbow; staff reported that during that shift the resident required a second staff member for transfer safety due to increased behaviors and lack of balance, but only one staff member was available, and there were no available staff to provide one‑on‑one supervision despite the resident’s continued attempts to self‑transfer. Later that day, the resident was found sitting on the floor near the bed after an unwitnessed fall and stated having hit the head; no injuries were initially noted, but the resident was sent to the hospital for evaluation. Hospital records documented admission following a fall with head trauma and critical subdural hematomas, after which the resident remained unresponsive and was transitioned to palliative care. Facility staff, including the unit manager and DNS, acknowledged that one‑on‑one supervision was needed for this resident after the first fall and that the scheduling coordinator was unavailable to find staff to provide it.
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