Failure to Adequately Supervise Resident to Prevent Injury
Penalty
Summary
A deficiency occurred when the facility failed to adequately supervise a vulnerable resident to prevent injury. The resident, who had severe cognitive deficits, was totally dependent on staff for dressing, toileting, and transfers, and required two staff members and a mechanical lift for transfers. She was observed with a large bruise under her right eye, which staff could not fully explain. The resident was unable to communicate how the injury occurred due to her cognitive condition. Staff hypothesized about possible causes, including accidental contact with the mechanical lift or her glasses, but no definitive cause was identified. The incident was first noticed by an LPN while the resident was in her wheelchair in the dining room, and neither the overnight nurse nor CNA on duty at the time were aware of any accident or incident that could have caused the bruise. The resident's care plan indicated she was at risk for falls and required staff to anticipate and meet her needs, including the use of a padded foot rest and regular toileting assistance. Despite these interventions, the facility was unable to determine how the injury occurred, and there was no documentation or witness to an event that could explain the bruise. The facility's policy required evaluation of injuries of unknown source and changes to the care plan to prevent recurrence, but the lack of supervision or failure to identify the cause of the injury led to the deficiency.