Resident Left Unattended During Care Results in Serious Fall Injury
Penalty
Summary
A deficiency occurred when a resident with a history of falls, severe cognitive impairment, legal blindness, and dependence on staff for all activities of daily living (ADLs) was left unattended during care. The resident's care plan identified her as high risk for falls and required staff assistance with mobility, transfers, and ADLs. Despite these documented needs, a CNA left the resident sitting on the edge of her bed while the CNA went to retrieve a towel from the bathroom, leaving the resident unsupervised. During this period of being left alone, the resident fell from the bed, resulting in a head injury, scalp laceration, hematoma/contusion to the forehead/scalp, traumatic subarachnoid hemorrhage, and a fracture to the C-1 vertebrae of her neck. The incident was discovered when the CNA heard a loud thump and returned to find the resident on the floor, bleeding from the head. The resident was subsequently assessed by nursing staff, who noted significant injuries and vital sign abnormalities, and was later transferred to the hospital for further evaluation and treatment. Interviews and record reviews confirmed that the CNA was aware of the resident's fall risk and the need for supervision but failed to ensure the resident's safety by leaving her unattended. The resident's care plan and fall risk assessments were not followed, and the CNA did not secure all necessary supplies before beginning care, resulting in the resident being left in a vulnerable position. The facility's investigation determined that the fall could have been prevented if the resident had not been left alone during care.