Failure to Provide Required Supervision During Toileting Results in Resident Fall and Death
Penalty
Summary
A deficiency occurred when a resident with a history of falls, dementia, and impaired decision-making capacity was left unsupervised on the toilet, contrary to her individualized care plan and the facility's 'Falling Star' protocol. The resident had experienced multiple falls in the months and days leading up to the incident, including several within a 24-hour period, and had been identified as high risk for falls. Her care plan required staff to remain in attendance while toileting, either in the bathroom or just outside the door, as part of the facility's fall prevention measures. On the day of the incident, the resident activated her call light, and an LPN assisted her onto the toilet. The LPN then left the resident unattended, reportedly to request assistance from a CNA, but camera footage did not confirm any interaction between the LPN and the CNA. The CNA assigned to the hallway did not respond to the call light, citing other responsibilities and a lack of direct assignment to the resident. The resident remained unsupervised for approximately eight minutes before staff responded, during which time she fell and sustained a severe head injury and hip fracture. The resident was found on the bathroom floor with a large hematoma on her left temple and reported hip pain. She was assessed by nursing staff and a nurse practitioner, and subsequently transferred to the hospital, where she was diagnosed with an acute subdural hematoma and an acute intertrochanteric fracture of the left femur. The resident's condition deteriorated, and she died shortly after the incident. The facility's investigation confirmed that staff were aware of the resident's high fall risk and the requirement for supervision during toileting, but failed to follow the established protocol.
Plan Of Correction
deficiency = "1. Resident R801 no longer resides at the facility.\n\n2. A facility-wide audit was completed by the Director of Nursing on 6/24/25 to identify other residents assessed to be high risk for fall (i.e., enrolled in the Falling Star Program). Plans of care for these residents were reviewed to ensure toileting and supervision interventions were in place. All residents enrolled in the Falling Star Program were issued a visual alert (star) on their room door and care card was updated. Residents requiring supervision while toileting were cross-checked for compliance with protocol that prohibits staff from leaving residents unattended.\n\n3. The policy "The Falling Star Program" was reviewed and updated to reflect the implementation of a visual alert on the hallway door.\n\n4. Re-Education of all staff:\na. As of 6/26/25, all licensed staff nurses and CNAs were re-educated on:\n• The facility's Falling Star Protocol and expectations.\n• Supervision requirements during toileting.\n• The process of direct communication during handoffs.\nb. Staff were tested post training to ensure comprehension. Competency validation included return demonstrations of supervised toileting protocol.\n\nc. Education with Licensed Nurses: Licensed nurses were instructed not to delegate supervision of high-risk residents without confirmed verbal acknowledgment from receiving staff.\n\n5. Monitor plan to Ensure Ongoing Compliance:" planOfCorrection = ""