Failure to Provide Adequate Supervision and Accident Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and assistance devices to prevent accidents for a resident with a history of repeated falls, moderate cognitive impairment, and multiple medical diagnoses including liver failure and dementia. The resident required staff assistance with activities of daily living and used a walker for transfers. The care plan identified the resident as being at risk for falls and included interventions such as keeping the bed in the lowest position and ensuring the call light was within reach. Despite these interventions, the resident experienced an unwitnessed fall during the early morning hours, which was not discovered for approximately three hours. On the night of the incident, the resident attempted to transfer from her bed to her chair using her walker and fell at approximately 3:20 AM. The resident's door was closed at her request, making it difficult for staff to hear her calls for help. The resident was not found until 6:20 AM by a nurse making morning rounds. During this time, the resident was heard calling for help on video footage, but staff did not respond. The last documented check by a CNA was at 2:30 AM, and the CNA did not check on the resident again during the remainder of the shift, citing a desire not to wake the resident. The facility's expectation was for staff to round on residents at least every two hours, but this was not followed. As a result of the fall, the resident sustained a fracture to her lower leg and required non-weight bearing status for four weeks. The incident was unwitnessed, and the resident was left on the floor for an extended period before being discovered. Staff interviews confirmed that rounding protocols were not adhered to, and the resident's call light was not within reach at the time of the fall. The deficiency was identified through observations, interviews, and record reviews, highlighting a failure to ensure adequate supervision and accident prevention measures for a resident at high risk for falls.