Failure to Provide Adequate Supervision and Assistance Resulting in Resident Falls
Penalty
Summary
The facility failed to provide adequate safety and supervision for two out of three sampled residents, resulting in falls. For one resident with diagnoses including dementia, osteoporosis, metabolic encephalopathy, muscle weakness, and a recent right femur fracture, the Minimum Data Set (MDS) indicated severe cognitive impairment and total dependence on staff for all activities of daily living (ADLs). On the evening of 2/17/2025, a Certified Nurse Assistant (CNA) provided bed mobility, dressing, and personal hygiene care to this resident without the assistance of a second staff member, despite facility policy and staff interviews confirming that a two-person assist was required for such dependent residents. During this care, the resident rolled off the bed and fell. Another resident, admitted with cerebral ischemia, dementia, and a history of facial fractures from a previous fall, also had severely impaired cognition and required varying levels of assistance for ADLs. Following a physician's order for continuous one-on-one supervision (1:1 sitter) after a fall, the facility failed to document or provide evidence that a sitter was assigned during a specific shift. On 4/28/2025, this resident experienced an unwitnessed fall and was found on the floor, despite the order for a 1:1 sitter and a bed alarm. Review of staffing assignments confirmed the absence of a designated sitter during the relevant shift. Interviews with facility staff, including the Director of Staff Development (DSD) and the Director of Nursing (DON), confirmed that the required supervision and assistance were not provided according to the residents' care plans and physician orders. Facility policies reviewed emphasized the need for appropriate staff assistance and supervision to prevent falls, but these were not followed in the cases described, directly leading to the residents' falls.