Failure to Provide Adequate Supervision During ADL Care Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a resident was not properly supervised during Activities of Daily Living (ADL) care, resulting in a fall with injury. The resident, who was known to be impulsive and had cognitive impairment, was being assisted by a CNA for morning dressing. The CNA turned her back momentarily while the resident was seated at the edge of the bed, during which time the resident fell forward and struck her head on the floor. The incident resulted in a large hematoma to the left forehead, ecchymosis to the left eye, a skin tear to the right elbow, and an abrasion to the left knee. The resident was later observed with significant bruising and was unable to respond appropriately during an interview. Staff interviews confirmed that the CNA was kneeling by the resident's feet, attempting to put on pants, when the fall occurred. After the fall, the CNA moved the resident before notifying the RN, which was not in accordance with facility protocol. The DON and the resident's DPOA both acknowledged the resident's impulsive behavior and cognitive deficits, with the DON stating that staff should be aware of these tendencies. The lack of adequate supervision and failure to follow post-fall procedures contributed to the resident's injuries.