Failure to Provide Adequate Supervision for High-Risk Resident Resulting in Fall and Hospitalization
Penalty
Summary
A resident with a significant history of falls, traumatic brain injury, hydrocephalus, vascular dementia, severe cognitive impairment, and mobility issues was not adequately supervised, resulting in an unwitnessed fall in their room. The resident's care plan identified them as high risk for falls and included interventions such as increased supervision, conducting rounds, and placing the resident in common areas for visual monitoring. Despite these interventions, the resident experienced multiple unwitnessed falls in their room, with the most recent incident occurring when the resident attempted to self-transfer from their wheelchair without assistance. At the time of the fall, the assigned CNA was assisting in the dining room, and the assigned nurse was at the nurse's station, leaving the resident unsupervised. Following the unwitnessed fall, the resident was initially assessed and found to have no apparent injury or change in condition, but later developed a bump on the head and subsequently experienced a massive seizure while being transported to the hospital. Hospital records indicated the resident suffered a significant head trauma, acute encephalopathy, and seizures, leading to hospice care. The facility's policy required staff to implement and adjust individualized fall prevention interventions based on ongoing risk and incident review, but the repeated unwitnessed falls and lack of supervision in the resident's room demonstrated a failure to provide adequate supervision and prevent accident hazards as required.