Failure to Provide Adequate Supervision During Bedside Care Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with dementia, major mood disorder, osteoporosis, and a completely impaired cognitive status was left unsupervised sitting on the side of her bed during care. The resident was documented as requiring substantial to maximal assistance for dressing and moving from lying to sitting, with care plans specifying that the bed should be in the lowest position when care was not being provided. Despite these interventions, a CNA left the resident sitting on the side of the bed while retrieving a top from the closet, during which time the resident fell to the floor. The CNA confirmed that the resident was not in her line of vision due to a pulled curtain and acknowledged that the resident needed significant help because of her weakness. Following the fall, the resident sustained a large hematoma on her forehead and was sent to the emergency room for evaluation. Clinical records and staff interviews confirmed the resident's ongoing need for total assistance due to poor balance and weakness. The facility failed to provide adequate supervision and assistance as required by the resident's care plan and documented needs, resulting in the resident's fall and injury.