Failure to Prevent Resident Fall Due to Inadequate Supervision and Assistance
Penalty
Summary
The facility failed to protect a resident from neglect by not providing adequate assistance and interventions to prevent a fall with injury. The resident, who had multiple diagnoses including anemia, gastrointestinal bleed, diabetes, stroke, sacroilitis, anxiety, difficulty walking, abnormal posture, and Stage 5 kidney disease, was assessed as having intact cognition and required moderate assistance for bed mobility. The resident's care plan identified her as being at risk for falls due to impaired balance and poor coordination, and specified that staff should provide necessary assistance during transfers and ambulation, as well as use bedrails as needed. On the day of the incident, the resident had recently returned from the hospital after a blood transfusion and required incontinence care. During care, a nurse aide turned the resident away from herself and then turned away to retrieve supplies, leaving the resident unsupervised. At this time, the resident rolled out of bed, resulting in a head laceration, subarachnoid hemorrhage, and a C4 cervical fracture. Bedrails were not present on the bed at the time, despite the resident's care plan indicating their use. Staff interviews confirmed that proper technique would have involved either using bedrails or turning the resident toward the caregiver, or obtaining a second staff member for assistance. The Director of Nursing and the Nursing Home Administrator confirmed that the nurse aide's actions constituted neglect, as the resident was not adequately supervised or assisted during care, directly leading to the fall and resulting injuries. Facility policies reviewed emphasized the importance of safe resident handling, use of bedrails when indicated, and the need to prevent neglect by providing necessary goods and services to avoid physical harm.