Failure to Provide Adequate Supervision for High Fall Risk Resident During Toileting
Penalty
Summary
A deficiency occurred when a resident, identified as high risk for falls due to multiple medical conditions including schizoaffective disorder, metabolic encephalopathy, unsteady gait, repeated falls, and vertigo, was not provided with adequate supervision during toileting. The resident had a documented history of falls and was enrolled in the facility's Falling Star Program, which visually identified her as a fall risk. Despite care plan interventions specifying that staff should fully assist the resident during restroom use and ensure safety during transfers, these interventions were not followed on the day of the incident. On the day of the event, the resident called out for help to use the bathroom, but staff did not respond promptly. The resident independently used her wheelchair to access the bathroom. A staff member responded to the resident's wheelchair alarm, found her in the bathroom, and offered assistance, which the resident declined. The staff member then left the resident alone in the bathroom, did not notify other staff, and did not activate the emergency call light. Shortly after, the resident attempted to transfer herself from the toilet to her wheelchair, which was not locked, and fell, resulting in a severe right ankle fracture. Interviews and record reviews confirmed that the resident required supervision or touching assistance with toileting, as indicated in her care plan and MDS assessment. Staff acknowledged awareness of the resident's fall risk status and the need for supervision, but failed to implement the required interventions. The resident suffered a displaced bimalleolar ankle fracture, required emergency transport, pain management, and subsequent surgery to repair the injury.