Failure to Provide Adequate Supervision Results in Resident Fall and Injury
Penalty
Summary
A resident with a history of Parkinson's disease, moderate cognitive deficits, and lower extremity impairments was admitted to the facility and assessed as high risk for falls. The resident required maximum assistance with toilet transfers. On the day of the incident, the resident was assisted to the toilet by nursing staff and then left alone for privacy at the resident's request. While unattended, the resident lost balance and fell into the bathtub, sustaining multiple rib fractures and experiencing pain. The fall was unwitnessed, and the resident waited approximately five minutes before staff responded to her calls for help. Interviews with staff confirmed that the resident was left unattended in the bathroom despite her need for significant assistance with transfers and her high fall risk status. The facility's own investigation and care plan documentation indicated that the resident should not have been left alone due to her impairments and risk factors. The facility's fall management policy required providing a safe environment and supervision to prevent accidents, which was not followed in this instance, resulting in harm to the resident.