Failure to Provide Safe Transfer and Supervision for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a history of falls and multiple diagnoses, including dementia, muscle wasting, and difficulty walking, was admitted to the facility and assessed as high risk for falls. The resident required substantial to maximal staff assistance with transfers, as documented in both the physical therapy evaluation and the certified nursing assistant task sheet. Despite these documented needs, staff failed to provide the necessary assistance, and the resident was allowed to self-transfer and self-toilet without supervision. On the day of the incident, the resident was found on the floor in his room, having attempted to go to the bathroom independently. The environment was free of clutter, and the call light was not activated. The resident reported tripping over his heel while trying to reach the bathroom, which was approximately eight feet away from where he was found. He sustained severe injuries, including fractures to the left shoulder and left hip, requiring emergency medical attention and surgical intervention. Staff interviews revealed a lack of awareness regarding the resident's need for assistance and a misunderstanding of his level of independence, despite clear documentation of his high fall risk and need for staff support. Additionally, the facility failed to implement targeted post-fall interventions to address the root cause of the resident's self-toileting behavior. The care plan did not include increased toileting assistance or supervision prior to the incident, and staff did not recognize or act upon the resident's history of impulsivity and previous falls. The deficiency was identified through record review and staff interviews, which confirmed that the resident did not receive the level of supervision and assistance required to prevent accidents.