Failure to Provide Adequate Supervision and Follow Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and follow the care plan for a resident with severe cognitive impairment, resulting in a fall. The resident had a history of dementia, anxiety disorder, a prior humerus fracture, and required substantial to maximal assistance with transfers and toileting according to the most recent MDS and care plan. Despite these documented needs, the resident was allowed to ambulate independently from the bathroom to her chair, during which she fell and sustained a significant skin tear and bruising, and later complained of pain in her right big toe and left arm. Staff interviews and documentation revealed inconsistencies in the assignment and supervision of care for the resident on the day of the fall. The care plan directed staff to provide assistance with transfers and all toileting tasks, but staff accounts indicated that the resident was often left to use the bathroom independently for privacy, with staff only nearby rather than providing direct assistance. There was also confusion among staff regarding the resident's level of independence, with some believing she was care planned to be independent for transfers and toileting, while others stated she required assistance. The care plan had not been updated to reflect changes in the resident's condition, and staff were not consistently following the documented interventions. Further, the facility's policies required ongoing assessment and adjustment of interventions for residents at risk of falls, as well as accurate documentation and communication among staff. However, the care plan was outdated, and staff were unclear about the resident's needs and the required level of supervision. The lack of direct supervision and failure to adhere to the care plan led to the resident's fall and injury, demonstrating a breakdown in communication, care planning, and implementation of fall prevention strategies.