Failure to Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident identified as high risk due to Alzheimer's disease, dementia, anxiety, poor safety awareness, impulsivity, a history of falling, and confusion. Clinical records and incident reports show that the resident experienced nine falls over a period of several months, with incidents occurring both from bed and from a wheelchair. The falls were documented at various times, primarily between early morning and early afternoon, as well as in the evening and late at night. Nursing documentation repeatedly noted the resident's confusion, restlessness, and frequent attempts to get up unassisted from bed or wheelchair, despite being unable to do so safely. Despite these ongoing behaviors and repeated falls, there was no documented evidence that the facility provided increased or adequate supervision during the times when the resident was most at risk. The care plan identified the resident as high risk for falls, but the documentation does not show that staff interventions were adjusted or intensified in response to the resident's persistent attempts to stand or transfer unassisted. The lack of documented supervision or intervention during these critical periods led to multiple falls and constitutes a failure to ensure the area was free from accident hazards and that adequate supervision was provided.