Failure to Provide Timely Toileting Assistance to High-Risk Resident Resulting in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, muscle weakness, and dementia, who was assessed as being at high risk for falls and totally dependent on staff for toileting, was left waiting for assistance for approximately 30 minutes after requesting help to use the bathroom. The resident's care plan and assessments clearly indicated the need for total assistance with toileting due to severe cognitive impairment and physical limitations. Despite these documented needs, the resident was not assisted in a timely manner after making the request to a CNA. During this period of waiting, the resident attempted to transfer herself to the bathroom without assistance. This resulted in an unwitnessed fall in the bathroom, where the resident was found on the floor with a laceration to the head and later diagnosed with a T5 compression fracture. Multiple staff interviews confirmed that the resident was known to be a high fall risk and required total assistance for toileting, and that the fall could have been prevented if the resident had been assisted promptly. Facility records, including the care plan, post-fall reviews, and staff interviews, consistently documented the resident's dependence and high risk for falls. The facility's own policy required appropriate support and assistance with activities of daily living, including toileting, for residents unable to perform these tasks independently. The failure to provide timely assistance directly led to the resident's fall and subsequent injuries.