Resident Fall Due to Inadequate Supervision During Care
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, non-ambulatory status, and total dependence on staff for activities of daily living was left without adequate supervision during incontinence care. While two staff members were changing the resident, one left the room to get a nurse after being alerted by a roommate's wife about another resident's vomiting, leaving the resident alone with a student nursing assistant (SNA). The SNA turned her back to get gloves, during which time the resident fell from the bed, which was in a raised position and without bed rails in place. The fall was unwitnessed, and the resident was found on the floor with a bleeding laceration on the left finger and a head injury. The resident, who was on blood thinners, was transported to the hospital for evaluation and treatment of the laceration but did not receive an x-ray of the injured finger at that time. Several days later, the finger was observed to be red, swollen, and warm, and an x-ray revealed a comminuted fracture. The resident was subsequently admitted to the hospital with cellulitis and a finger fracture. Documentation and interviews confirmed that staff failed to ensure the resident's safety by leaving the resident unattended during care, not ensuring the bed was in the lowest position, and not maintaining appropriate support, directly leading to the fall and subsequent injuries.