Failure to Provide Adequate Supervision Resulting in Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with Parkinson's disease, Alzheimer's disease, reduced mobility, and insomnia. The resident, who was cognitively intact according to the most recent MDS, had a care plan that included monitoring for fall risk, poor balance, and insomnia, as well as a preference for outdoor activities such as gardening. Despite these documented needs and risks, staff did not properly visualize the resident during required safety rounds at night. Specifically, the LPN responsible for the midnight census did not physically check the resident, and the CNA performing two-hour rounds relied on seeing the resident's feet from the doorway rather than entering the room to confirm the resident's presence. On the night of the incident, the resident left his room and accessed the facility's courtyard without staff awareness. The resident was later found lying face down on the concrete walkway in the courtyard, having fallen from his wheelchair. Staff interviews revealed that it was not standard practice to check the courtyard during nightly rounds, and staff were unaware that the resident had previously attempted to go outside at night. The CNA stated that rounds were performed every two hours but did not include the courtyard, and the LPN confirmed that the charge nurse did not perform room-to-room checks at midnight as expected by facility policy. Interviews with other residents and staff indicated that the resident was known to be active at night and had a history of going outside or attempting to do so. However, this behavior was not consistently monitored or addressed by staff during their rounds. The lack of direct visualization and failure to include the courtyard in safety checks resulted in the resident being unsupervised outside for an undetermined period, leading to a fall and subsequent medical evaluation.