Failure to Provide Adequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of falls, and significant physical limitations was not provided with the necessary supervision to prevent accidents. The resident, who had diagnoses including Alzheimer's disease, dementia, and a previous right femur fracture, was assessed as a high fall risk and required frequent observation and placement in supervised areas when out of bed. Despite these documented needs, the resident experienced multiple falls within a month, including incidents resulting in a laceration and a left hip fracture. On the day of the most serious incident, both the assigned LPN and CNA left the unit floor without notifying other staff, contrary to facility policy requiring staff to ensure coverage when leaving their assigned area. The resident was left unsupervised in the dining room, seated in a wheelchair, and was later found on the floor by another CNA who responded to calls for help. Staff interviews confirmed that the resident was known to attempt to stand unassisted and should not have been left out of sight due to her impulsive behavior and high fall risk. Documentation and staff statements revealed that the facility's process for ensuring adequate supervision and staff coverage was not followed, resulting in the resident being left alone and sustaining injuries including rib fractures and a left femoral neck fracture. The facility's policies required adequate staffing and supervision, especially for residents at high risk for falls, but these procedures were not adhered to at the time of the incident.