Failure to Prevent Avoidable Fall Due to Inadequate Supervision and Staffing
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of stroke, and total dependence for care experienced a fall. The resident was admitted with diagnoses including dysphagia and was identified as a high fall risk. On the night of the incident, only two CNAs were scheduled to care for 50 residents. After one CNA changed the resident's brief, the bed was not pushed back against the wall as required. Approximately 30 minutes later, the resident was found on the floor between the bed and the wall, yelling and crying to get staff attention. The resident did not sustain injuries and refused hospital evaluation. Interviews with staff and a family member confirmed that the fall resulted from the failure to reposition the bed after care and that staffing levels were insufficient to meet resident needs, especially given the high acuity of the population. Both CNAs and facility leadership acknowledged that only two CNAs were present during the shift, which was not adequate for the number of residents and their care requirements.