Failure to Provide Adequate Supervision and Assessment for High Fall Risk Resident
Penalty
Summary
A cognitively impaired female resident with a history of falls and multiple medical diagnoses, including dementia, unsteadiness on her feet, and abnormal posture, was not provided with appropriate and sufficient supervision despite being identified as a high fall risk. The resident's care plan did not address the need for constant close supervision, and her fall risk assessment was inaccurate, failing to reflect a recent fall. On the day of the incident, the resident was left unsupervised near the nurse's station while her assigned CNA was attending to another resident in a different hall, and no staff were present at the nurse's station at the time of her fall. The resident attempted to stand from her wheelchair, lost her balance, and fell face down, resulting in a bloody abrasion on her forehead. Staff responded after hearing the fall, but the resident was not under direct supervision at the time, despite staff acknowledging that she required constant monitoring. Interviews revealed inconsistencies in staff accounts regarding supervision and the implementation of fall precautions, with some staff stating that residents at high risk of falls should be closely supervised by sitting alongside them or being near them at all times. Following the fall, the resident was assessed by staff, who noted abrasions and bleeding but did not send her to the hospital for further evaluation. The facility did not conduct x-rays or a comprehensive injury assessment, relying instead on neuro checks and monitoring. The incident was not reported to the State, as the facility determined there was no major injury without hospital evaluation. The lack of accurate assessment, supervision, and appropriate response to the fall constituted a failure to ensure the resident's safety and prevent accidents.