Failure to Ensure Competent Staff and Adequate Supervision Resulting in Fatal Resident Fall
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies to care for residents, as evidenced by an incident involving a resident who suffered a fatal fall. Video surveillance showed that two agency GNAs left a resident unsupervised in a reclined Geri chair at the nurses' station, despite the resident previously attempting to get out of the chair unassisted. After being left alone, the resident attempted to walk unassisted, fell, and sustained a head injury. Review of the agency GNA's personnel file revealed no evidence of competency evaluation or training specific to the facility, and interviews with facility staff confirmed there was no process for training or evaluating agency staff, nor documentation of orientation or shadowing. Following the fall, the response by nursing staff was inadequate. The RN who responded failed to properly assess the resident for injuries before moving them, did not conduct a neurological assessment, and left the resident before rendering first aid. The RN was unaware of the worsening head injury and did not check on the resident again until EMS arrived 36 minutes later. Additionally, 911 was not called until 31 minutes after the fall. The resident was observed to have a large knot on the temple and a nosebleed, and later died at the hospital due to injuries from the fall.