Failure to Provide Adequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident who was at moderate risk for falls and had a history of seizures and cognitive impairment. The resident required substantial to maximal assistance with activities of daily living, was incontinent, and used a wheelchair. The care plan included interventions to anticipate and meet the resident's needs and to monitor for signs and symptoms of tremors, rigidity, dizziness, changes in consciousness, and slurred speech. Despite these documented needs and interventions, the resident was left unsupervised in the dining room during a busy lunch period. On the day of the incident, all four CNAs assigned to the floor were occupied with passing meal trays and feeding other residents in their rooms, leaving the dining room without staff supervision. The nurse supervisor was also engaged in another resident's care and not present in the dining room. The CNA assignment sheet indicated that staff were scheduled to monitor the dining room in 30-minute increments, but at the time of the fall, no staff were present to supervise the residents in the dining room. The staff responsible for monitoring the dining room did not inform anyone before leaving, resulting in a lapse in supervision. As a result, the resident attempted to get up from the wheelchair and fell, sustaining a laceration to the right temple that required sutures. The fall was unwitnessed, and the resident was found on the floor exhibiting seizure-like symptoms. The incident was reported to the state agency, and the resident was transported to the hospital for evaluation and treatment. Facility policies required supervision of residents, especially those at risk for falls and seizures, but these were not followed at the time of the incident.