Failure to Provide Adequate Supervision and Care Planning for High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with hemiplegia, hemiparesis, and Alzheimer's disease, who was assessed as having severely impaired cognition and was dependent on staff for all activities of daily living (ADLs) and bed mobility, was not provided with adequate supervision during care. The resident was identified as high risk for falls and required two-person assistance for all ADLs, including turning and repositioning. However, documentation and staff interviews revealed that the resident was turned and changed by only one certified nursing assistant (CNA), resulting in the resident rolling off the bed and falling to the floor. The incident was confirmed by progress notes and interviews with facility staff, who acknowledged that two-person assistance was necessary for the resident's safety during such activities. Additionally, the facility failed to develop and implement an individualized, person-centered care plan addressing the resident's high risk for falls prior to the incident. Despite the resident's documented needs and risk factors, there was no care plan in place to guide staff in providing the necessary care and services to prevent falls and injuries. Facility policies required comprehensive care plans to be developed within a specified timeframe after assessment, but this was not completed for the resident before the fall occurred.