Failure to Provide Adequate Supervision and Monitoring Resulting in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for residents, resulting in a significant incident where a resident with a high risk for falls sustained serious injuries during a shower. The resident, who had a history of falls, cognitive impairment, lack of coordination, and required maximal assistance with bathing, was being showered by a CNA who left the resident momentarily to retrieve towels. During this time, another CNA was present but was occupied putting on gloves and not in direct contact with the resident. The resident became agitated, attempted to ambulate, and fell, sustaining complex facial lacerations that required 12 sutures. The incident was witnessed by staff who reported that the resident should not have been left unattended, even briefly, given his known fall risk and behavioral tendencies. Additional observations during the survey revealed lapses in supervision and monitoring in other areas of the facility. On the second floor, a CNA was found using her phone in an empty resident room while a resident was calling for assistance, indicating inattentiveness to resident needs. On the third floor, two residents assessed as high risk for falls were observed sitting unsupervised in the activity room, contrary to facility policy that requires continuous monitoring in such settings. The CNA responsible for monitoring these residents was not present at the time but later stated she was assigned to supervise the area during that period. Facility policies reviewed by the surveyor specify that residents requiring staff assistance should not be left alone during bathing or showering and that supervision is a core component of resident safety. Despite these policies, staff actions did not align with established protocols, as evidenced by the incident in the shower room and the lack of supervision in other areas. The failure to maintain adequate supervision and monitoring directly affected multiple residents identified as high risk for falls, resulting in preventable harm.