Failure to Prevent Resident Fall Due to Inadequate Supervision and Environmental Hazard
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including Bipolar Disorder, COPD, metabolic encephalopathy, and a right artificial shoulder joint, experienced a fall resulting in a fractured femur. The resident was assessed as having intact cognition but exhibited delusions and impulsive behaviors, and required supervision for all activities of daily living and toileting. The care plan identified the resident as being at risk for falls, with a history of wheelchair use and independent ambulation. On the night of the incident, the resident attempted to get up from bed to use the bathroom and slipped on a wet floor caused by a spilled cup of water. A CNA observed the water on the floor and instructed the resident not to get up while she left the room to obtain cleaning supplies. Despite these instructions, the resident attempted to stand and subsequently fell, sustaining a comminuted and displaced distal femur fracture that required surgical intervention. The CNA later acknowledged that she should have ensured someone stayed with the resident or activated the call light until the hazard was addressed. Facility policy required routine assessment of the care environment for extrinsic risk factors and prompt corrective action to prevent falls. However, the failure to provide adequate supervision and to immediately address the environmental hazard directly contributed to the resident's fall and injury. The incident investigation identified the wet floor and the resident's impulsivity as contributing factors, and staff interviews confirmed that supervision was insufficient at the time of the event.