Inadequate Supervision in Dining Area Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision in the dining area, resulting in a resident-to-resident incident that led to a fall. Two residents with dementia and cognitive deficits, both residing in the memory care unit, were involved. During a noon meal, one resident attempted to move into a spot at the table occupied by another resident. In the process, there was physical contact, and the first resident lost her balance and fell to the floor. There were no staff witnesses to the incident, and another resident present could not recall staff being in the area at the time. On the day of the incident, only one staff member was monitoring the dining room, as other staff were either on break or passing meal trays. The sole staff member left the area to answer a phone call, leaving the dining room unsupervised. This absence of supervision allowed the incident to occur without immediate intervention. Following the fall, the resident was found to have bruising on her buttock and was sent to the emergency room for evaluation, as per facility protocol for unwitnessed falls.