Failure to Supervise High Fall Risk Resident During Toileting and Omission of Gait Belt Use
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and utilize required safety devices for a resident identified as high risk for falls. The resident, who had a history of a displaced fracture of the right tibia and patella and was under partial weight-bearing orders with a knee immobilizer for out-of-bed activities, was assisted to a bedside commode by a CNA. The CNA did not use a gait belt during the transfer, did not apply the resident's knee immobilizer, and left the resident alone for privacy, despite the resident's high fall risk status as documented in the care plan and fall risk evaluation. The resident subsequently attempted to stand up from the commode, reached for a walker and the call light, and fell when the commode shifted behind her. The fall resulted in a fractured left wrist. The call light had been placed out of easy reach, and the resident was left unsupervised for approximately ten minutes. The CNA left the room to respond to another emergency and did not inform another staff member to supervise the resident during this time. Interviews with facility staff, including the CNA, treatment nurse, DSD, and DON, confirmed that facility policy required staff to remain with high fall risk residents during toileting and to use gait belts during transfers. The staff acknowledged that the required supervision and use of assistive devices were not provided, and that the resident should not have been left alone on the commode.