Failure to Provide Adequate Supervision to Prevent Falls
Penalty
Summary
The facility failed to provide effective supervision to prevent avoidable falls for two residents identified as high risk for falls. One resident, who was severely cognitively impaired and had a history of falls, was left in the dining room for closer monitoring. Despite this, the assigned nurse aide was found asleep with her back to the resident, and another nurse observed the resident attempting to stand but did not intervene because she was not assigned to that resident. The resident subsequently fell, sustaining a collarbone fracture and a hematoma on the forehead, and required hospitalization. Documentation and interviews confirmed that staff were aware of the resident's fall risk and the need for close monitoring, but failed to provide adequate supervision at the time of the incident. Another resident, with a history of seizures, cerebral vascular accident, and vascular dementia, was also at high risk for falls and required substantial assistance with transfers. On the day of the incident, a nurse aide assisted the resident to the toilet, instructed him to use the call bell when finished, and left the resident unattended in the bathroom. The resident did not use the call bell and attempted to transfer himself, resulting in a fall and a minor head laceration. The nurse aide was new to the facility and was not fully familiar with the resident's care needs, and the resident was known to be noncompliant with using the call bell for assistance. In both cases, the lack of effective supervision and failure to follow established care plans and interventions for high-risk residents directly led to avoidable falls and injuries. Staff interviews and documentation revealed lapses in monitoring, communication, and adherence to resident-specific safety measures, contributing to the deficiencies identified during the survey.