Failure to Provide Required Supervision During Out-of-Facility Appointment Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, poor safety awareness, and a history of falls was not provided with the care-planned level of supervision during an out-of-facility medical appointment. The resident, who required two-person maximal assistance for toilet transfers and sitting to standing, was left unattended in the clinic lobby after her appointment while waiting for facility transportation. The facility's transportation driver, whose role was limited to driving, checked the resident in and left her in the lobby without a staff assistant, despite the resident's care plan indicating the need for such supervision. Clinic staff were not informed that the resident required assistance, and after the appointment, the resident was left alone in the waiting area. The resident subsequently went to the bathroom unaccompanied, locked the door, and fell while attempting to transfer herself from a seated position. She was found on the floor by clinic staff after they heard her calling for help. The incident resulted in a pelvic fracture, confirmed by a CT scan, and required transfer to the hospital for evaluation and treatment. Interviews with facility staff revealed that the process for determining which residents required staff assistance for out-of-facility appointments was not consistently followed. The transport form for the appointment was not properly completed to indicate the need for caregiver assistance, and the staff member responsible did not identify themselves on the form, preventing follow-up. Both facility and clinic staff confirmed that the resident was not safe to transfer or sit to stand without assistance, and that she had a history of attempting self-transfers. The lack of adequate supervision and failure to follow the resident's care plan directly led to the accident and injury.