Resident Left Unattended on Toilet Resulting in Serious Fall and Injuries
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, cognitive impairment, and significant physical limitations was left unattended on the toilet by staff, resulting in a fall that caused serious injuries, including fractures to the femur and left hip, intracerebral hemorrhage, and skin tears. The resident was dependent on staff for all activities of daily living (ADLs), had a BIMS score indicating moderate to severe cognitive impairment, and was frequently incontinent, requiring substantial to maximal assistance. The care plan specifically indicated that the resident should not be left unattended in the bathroom and required the use of a communication board due to language and cognitive barriers. However, the communication board was not present in the room at the time of the incident, and staff were not observed using it to communicate with the resident. On the day of the incident, a CNA who did not speak the resident's primary language assisted her to the toilet and left her alone after the resident gestured for privacy. The CNA did not ensure that another staff member was actively monitoring the resident, despite being aware of her fall risk and cognitive limitations. The resident was left unsupervised for several minutes, during which time she fell and sustained significant injuries. Interviews with staff revealed confusion and lack of clarity regarding who was responsible for monitoring the resident, and the CNA involved was not familiar with the resident's care needs or fall risk status. Additionally, the resident was unable to use the call light due to her cognitive impairment, a fact confirmed by both the resident and her family members. The facility failed to ensure that the resident received adequate supervision and assistive devices as required by her care plan and professional standards. The lack of effective communication tools, failure to follow the care plan, and inadequate staff communication and training directly contributed to the resident being left unattended and subsequently falling. The incident was not promptly investigated or self-reported to the appropriate authorities, and there was inconsistency in staff accounts of the event, further highlighting the breakdown in supervision and care.