Failure to Supervise High Fall Risk Resident on Admission
Penalty
Summary
A deficiency occurred when a resident with a high risk for falls was not adequately supervised upon admission to the facility. The resident, who had diagnoses including vascular dementia, wet gangrene, and osteomyelitis, arrived at the facility before the start of the incoming nurse's shift and had not yet been officially admitted or assessed by nursing staff. Both the registered nurse and the CNA on duty were aware that the resident was a high fall risk, but the resident had not been evaluated for mobility or supervision needs prior to the incident. The CNA reported that she found the resident attempting to get up from bed and, unsure of the resident's mobility status, suggested the use of a urinal and unfolded a walker without confirming if it belonged to the resident. The CNA then left the room to dispose of trash, during which time the resident attempted to get up independently and fell. The fall was unwitnessed, but the resident was found on the floor, reported head and back pain, and was subsequently sent to the hospital for evaluation. Following the fall, the resident's daughter reported ongoing pain, which led to further assessment and the discovery of a minimally displaced rib fracture. The facility's policy required that the environment be free of accident hazards and that residents receive adequate supervision to prevent accidents. In this case, the lack of timely assessment and supervision for a high-risk resident directly led to the fall and injury.