Failure to Provide Adequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
Facility staff failed to provide adequate supervision to prevent accidents for a resident with significant cognitive and physical impairments. The resident had a history of vascular dementia, muscle weakness, and recent fractures, and was assessed as requiring partial/moderate assistance for ambulation, meaning staff were expected to physically assist and supervise the resident while walking. The care plan identified the resident as a fall risk and included interventions such as assisting with ambulation and transfers, and following therapy recommendations for supervision. Despite these documented needs, the resident experienced an unwitnessed fall in another resident's room, resulting in a closed nondisplaced fracture of the second cervical vertebra and a closed nondisplaced intertrochanteric fracture of the right femur, as well as a skin tear. Staff interviews revealed that the resident was not being supervised at the time of the fall, and that there was insufficient staffing on the memory care unit to provide the required level of supervision. The LPN on duty reported that only two CNAs were available, which was not enough to ensure proper supervision of all residents, particularly those at high risk for falls. Further interviews indicated a lack of communication regarding the resident's need for assistance with ambulation. A CNA stated that staff were not aware the resident required partial/moderate assistance, and that such information was not communicated to CNAs. The therapy team also confirmed the resident required supervision and occasional verbal cues while using a walker. Documentation and staff statements consistently showed that the resident's need for supervision was known but not implemented at the time of the incident, directly leading to the fall and resulting injuries.