Failure to Provide Scheduled Toileting and Supervision Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and scheduled toileting for a resident with a history of falls and severe cognitive impairment. The resident's care plan required supervision, regular toileting every three hours, and that she be kept in common areas for monitoring. Despite these interventions being documented, staff did not follow the care plan on the day of the incident, resulting in the resident not being toileted between 4:51 a.m. and 9:29 p.m., with a significant gap in care during the evening hours. On the day of the incident, the resident was last toileted at 4:30 p.m. and was observed at the nurse's station and dining room throughout the afternoon and early evening. However, she was allowed to return to her room unsupervised at approximately 8:22 p.m. Staff did not redirect her to the common area or provide the scheduled toileting. Shortly after, staff found her on the bathroom floor with a head laceration, which required emergency medical attention and resulted in hospitalization. The resident was unable to use the call light and had a history of attempting to self-transfer, which increased her risk for falls. Interviews with staff and review of documentation confirmed that the care plan was not followed, specifically regarding scheduled toileting and supervision. Staff acknowledged that the resident should have been toileted and kept within sight, and that failure to do so likely contributed to her attempting to toilet herself, leading to the fall and injury. The facility's own investigation and camera footage corroborated that the resident was not provided the required supervision or assistance as outlined in her care plan.