Failure to Supervise High-Risk Resident Outside Facility Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including CHF, COPD, atrial fibrillation, anxiety disorder, and personality disorder, was left unsupervised outside the facility, resulting in a fall with injury. The resident was assessed as having intact cognition but required substantial assistance for bed mobility and was dependent on staff for transfers. The Morse Fall Scale identified the resident as high risk for falls due to a history of falls, weak gait, and poor safety awareness. The care plan specified interventions such as ensuring appropriate footwear, anticipating needs, and maintaining a safe environment, but did not specifically address supervision outside the facility. On the day of the incident, the resident independently moved in a wheelchair to the main entrance, exited the building, and sat outside unsupervised. The main entrance area was observed to have a steep decline, making it unsafe for wheelchair use. The resident leaned forward to pick up an object from the ground and fell out of the wheelchair, sustaining a laceration to the forehead and an abrasion to the nose. The resident was found on the ground by staff, assessed, and transferred to the hospital for evaluation and treatment of the injuries. The investigation revealed that the main entrance door had been switched from night mode (requiring staff assistance to open) to day mode (automatic opening), allowing residents to exit unsupervised. This change was made by a nursing assistant who was interrupted by the door buzzer while providing care and decided to switch the door mode for convenience. There was no staff present at the receptionist desk at the time, and staff were not aware that the area was unsupervised. Facility policies regarding door locking and criteria for resident supervision outside were not provided.