Failure to Provide 1:1 Supervision and Address Environmental Hazards Resulting in Resident Injury
Penalty
Summary
The facility failed to provide required one-to-one (1:1) supervision for a resident with a significant history of falls and severe cognitive impairment, as outlined in the resident's care plan. Despite documented interventions for 1:1 supervision and the use of a geriatric chair for rest periods, staff did not consistently implement or document 1:1 supervision, particularly during the evening and night shifts. The resident, who had multiple risk factors including cauda equina syndrome, muscle weakness, dementia, and a history of frequent falls, was left unsupervised after being placed in bed, with staff relying on the placement of a geriatric chair next to the bed as a barrier rather than direct supervision. On the night in question, the resident was found in the hallway complaining of eye pain and was subsequently lowered to the floor by a nurse after being unable to support their own weight. Hospital records later indicated that the resident had sustained a type II fracture of the odontoid process and a facial contusion, with evidence suggesting the injuries may have occurred while the resident attempted to climb over the geriatric chair placed beside the bed. Staff interviews revealed that the practice of placing the geriatric chair next to the bed was routine, despite knowledge that the resident had a history of attempting to climb over or out of the chair, and that 1:1 supervision was not provided during the night shift due to staffing limitations. The facility's investigation into the incident did not fully consider all potential causal factors, such as the environmental hazards posed by the placement of the geriatric chair and the lack of direct supervision. Additionally, a rolling computer chair was observed in the resident's room when not in use, presenting another accident hazard. There was no documentation of when 1:1 supervision was provided, how its effectiveness was evaluated, or how decisions regarding the initiation or discontinuation of 1:1 supervision were made. The facility's failure to recognize and address these hazards and to follow the resident's care plan for fall prevention directly contributed to the resident's injuries.