Failure to Provide Adequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
Staff failed to provide adequate supervision to a resident with Alzheimer's disease and dementia, who was identified as high risk for falls. The resident's care plan specifically instructed staff not to leave her unattended due to her tendency to attempt self-transfers. Despite these instructions, a CNA left the resident alone at the nurse's station while responding to another call light, without notifying other staff members. At the time, all other staff were occupied in other rooms, leaving the resident unsupervised. As a result of being left unattended, the resident experienced an unwitnessed fall, which led to a left hip fracture. The resident required surgical intervention and subsequent skilled nursing care for pain management and rehabilitation. Facility records, including the resident's MDS, fall risk assessment, and care guide, all indicated the need for supervision and highlighted the resident's history of multiple falls. Interviews with staff and the interim DON confirmed that the resident should have been supervised at all times, especially during meals, and acknowledged that the fall could have been prevented with proper supervision.