Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident, identified as Resident R6, leading to an accident. Resident R6, who was admitted to the facility in 2017, has a history of muscle weakness, macular degeneration, and allergic rhinitis, and is moderately cognitively impaired with a BIMS score of 12. The resident is dependent on assistance for activities such as toileting, transfers, and bathing, and requires supervision for personal hygiene tasks. On the day of the incident, the resident was left alone in the bathroom to brush her teeth, with the wheelchair's right lock not secured, despite being dependent on assistance for such activities. The incident occurred when the resident was found on the bathroom floor with a laceration on the right side of her head and a skin tear on her left forearm. The resident was not communicating with staff and was later diagnosed with a comminuted proximal humeral fracture. Staff statements indicated that the resident was left alone after being asked if she needed more time, and the bathroom call bell cord was draped around the sink faucet. The Director of Nursing confirmed the facility's failure to provide adequate supervision and assistance, contributing to the resident's fall and subsequent injuries.
Plan Of Correction
Resident R6 was re-evaluated by therapy for her ability to be left unsupervised at the bathroom sink to promote independent self-care such as but not limited to washing their face, brushing their teeth. The plan of care has been updated. All residents will be re-evaluated to determine who can be left unsupervised at the bathroom sink to promote independent self-care such as but not limited to washing their face, brushing their teeth. This will be noted in the plan of care as indicated. Nurses, Nursing Assistants, and Therapists will be educated by the Director of Nursing and/or designee on who can be left unsupervised at the bathroom sink to promote independent self-care such as but not limited to washing their face, brushing their teeth. The details will be noted in the plan of care as indicated. Audits will be conducted by observing staff providing care and asking staff how to identify who can be left unsupervised at the bathroom sink to promote independent self-care such as but not limited to washing their face, brushing their teeth. Ten random audits will be completed weekly for 4 weeks or until substantial compliance is achieved. Results will be reviewed at the Quarterly QA meeting.