Resident Left Unsupervised on Bedside Commode Despite Fall Risk
Penalty
Summary
A resident with a history of left leg fracture, anxiety, and difficulty walking was identified as high risk for falls upon admission. The care plan specified that the resident's call light should always be within reach and that the resident should not be left unsupervised in the bathroom or on the bedside commode. On the morning in question, the resident activated the call light while on the bedside commode, but staff did not respond for 21 minutes. During this time, the resident self-transferred back to bed, as confirmed by both the resident and staff observations. Further investigation revealed that the CNA who assisted the resident onto the bedside commode left to complete a shower for another resident and notified other staff by radio, but was unaware that the resident was not to be left alone on the commode. The Director of Nursing Services confirmed that the resident's care plan required supervision while on the bedside commode. This lapse in following the care plan resulted in the resident being left unsupervised, placing the resident at risk for accidents.