Failure to Provide Adequate Supervision for Fall Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as a fall risk, resulting in multiple falls. The resident, an elderly male with severe unspecified dementia, anxiety, and altered mental status, was admitted with a care plan indicating a risk for falls due to weakness and a new environment. On two separate occasions, the resident was left unsupervised or insufficiently supervised due to staffing shortages. On one occasion, the resident attempted to go to the bathroom alone, fell, and hit his head, requiring hospital evaluation. Staff interviews confirmed that the resident should not have been left alone and that the unit was short-staffed at the time of the incident. On another occasion, the resident, who was supposed to be kept in the common area for supervision, was able to stand up and fall before staff could intervene, again resulting in a head injury and hospital evaluation. Documentation and staff statements consistently indicated that the resident was not provided the necessary supervision as outlined in his care plan, and that staffing levels were below normal on both days when the falls occurred. The facility's records confirmed the occurrence of both falls within a short period.