Failure to Provide Adequate Supervision and Fall Precautions
Penalty
Summary
A deficiency occurred when a resident with multiple high-risk factors for falls, including muscle weakness, impaired gait, dependence on a wheelchair, and a history of falls, was left unsupervised sitting on the side of her bed by a CNA. The CNA left the resident momentarily to retrieve a sit-to-stand lift, during which time the resident slid off the bed and sustained a distal femoral shaft fracture, later requiring surgical repair. The resident's care plan indicated a need for dependent staff assistance with transfers using a mechanical lift and substantial/maximal assistance for bed mobility, but these interventions were not followed at the time of the incident. Additionally, the care plan failed to document the use of gripper socks as an intervention, despite this being identified in the fall investigation. Interviews with facility leadership confirmed that the resident was considered a high fall risk and should not have been left sitting on the bedside unsupervised. The facility's fall policy required individualized care planning and implementation of interventions for high-risk residents, which was not adequately executed in this case.