Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision to a resident with a significant risk for falls. The incident involved a resident with a history of multiple falls, dementia, impaired balance, and other co-morbidities, who was found sitting on the floor after being left unsupervised. At the time of the incident, a CNA assigned to supervise the resident in the dining room was observed attending to her cellphone and was unaware that the resident had slid off the wheelchair. The incident was reported by another resident, not by staff, indicating a lapse in direct supervision. The resident's care plan and fall risk assessment identified her as being at high risk for falls, with interventions in place such as offering toileting after dinner and monitoring due to impulsivity and unsteadiness. Despite these documented risks and interventions, the staff member responsible for supervision was distracted and did not notice the resident's fall. Facility policy requires staff to provide an environment free from accident hazards and to supervise residents to prevent avoidable accidents, but this was not followed in this instance.