Resident Left Unsupervised on Patio Resulting in Fatal Fall
Penalty
Summary
A deficiency occurred when a restorative nursing assistant (RNA) left a resident, who was at moderate risk for falls and had significant cognitive and physical impairments, unsupervised on an outdoor patio for approximately 30 minutes. The resident had a history of vascular dementia, hemiplegia, muscle weakness, and was dependent on staff for all mobility and activities of daily living. The resident's care plan identified a need for a safe environment, assistance with all ADLs, and interventions to minimize fall risk, but did not specify supervision requirements for outdoor activities. On the day of the incident, the RNA took the resident outside in a wheelchair and left him alone on the patio, without informing other staff or ensuring supervision. The patio was not fully visible from the nursing stations, and there was no method for the resident to call for help. Staff interviews confirmed that the resident was not alert, was dependent on staff, and should not have been left unsupervised. The resident was later found on the ground, unresponsive, next to his wheelchair, having sustained a major head injury. Medical evaluation revealed a subdural hematoma with midline shift, and the resident was transported to the hospital for emergency care. The incident resulted in a significant decline in the resident's condition and ultimately led to death. Staff statements and record reviews confirmed that the lack of supervision and failure to communicate the resident's location contributed directly to the fall and subsequent injury.