Failure to Provide Adequate Supervision for High-Risk Resident with Visual Impairment and Dementia
Penalty
Summary
A deficiency occurred when the facility failed to provide an environment free from accident hazards and did not ensure adequate supervision and monitoring for a resident with significant fall risk and cognitive impairment. The resident, who had diagnoses of dementia, Alzheimer's disease, and a history of fractures, was assessed as being at high risk for falls due to unsteady gait, poor safety awareness, and impaired cognition. The care plan identified the need for interventions such as regular fall risk assessments and supervision, but these were not consistently implemented. On observation, the resident was seen walking unsupervised in her room with her eyes closed and hands outstretched, repeatedly running into a wall near the restroom area. No staff were present to assist or redirect her, and no bed or chair alarm was heard during the incident. Interviews with staff confirmed that the resident had recently developed new behaviors, including walking with her eyes closed due to eye irritation, which further increased her fall risk. Staff acknowledged that the resident required increased assistance and supervision, including 1:1 supervision for safety, but this was not provided at the time of the incident. Review of facility policies indicated that maintaining resident safety and providing adequate supervision are facility-wide priorities, with individualized interventions required to address specific risks. However, the care team did not update the care plan to address the resident's new behavior of walking with eyes closed, and interventions to mitigate the increased risk were not implemented or documented. This lapse in supervision and failure to modify interventions as needed led to the resident being left unsupervised despite her high risk for falls and injury.