Failure to Provide Adequate Supervision During Toileting Results in Resident Fall
Penalty
Summary
A resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, lack of coordination, and reduced mobility was identified as being at risk for falls and dependent for toileting. The resident's care plan and fall risk assessment documented these risks and the need for staff assistance. On the date of the incident, the resident was being assisted with toileting by a CNA, who stepped out of the room to provide privacy while the resident was on the toilet, leaving the resident unattended. The resident's family was present in the room at the time. The resident subsequently fell off the toilet and was found lying on the bathroom floor by staff after being alerted by the family. The facility's Fall Prevention Program Policy states that residents requiring staff assistance should not be left alone after being assisted to bathe, shower, or toilet. Despite this policy, the CNA left the resident unattended, resulting in a fall. Interviews with facility staff confirmed that the CNA left the room and relied on the family to notify staff when the resident was finished, contrary to facility policy.