Failure to Provide Required 1:1 Supervision Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, dementia, adjustment disorder with anxiety, and urinary retention requiring an indwelling foley catheter was not provided with adequate supervision as required by their care plan. The care plan specified 1:1 observation at all times due to the resident's fall risk. Despite this, a staff member left the resident unattended in the room after providing care, believing the resident was asleep and would not be at risk during her brief absence. During the staff member's absence, the resident fell and was found on the floor undressed, without anti-skid socks, and with a dislodged foley catheter. The incident resulted in the resident being sent to the emergency room for catheter reinsertion. Staff interviews confirmed that the resident was supposed to be under continuous 1:1 supervision for safety, regardless of whether the resident was awake or asleep, but this protocol was not followed at the time of the incident.