Resident Left Unsupervised on Patio Resulting in Fatal Fall
Penalty
Summary
A deficiency occurred when a Restorative Nursing Assistant (RNA) left a resident with vascular dementia, hemiplegia, and a history of falls alone on a facility patio for approximately 30 minutes. The resident was known to be dependent on staff for all mobility, had impaired cognition, and was classified as a moderate fall risk. The resident's care plan required staff to provide a safe environment, prompt response to requests for assistance, and appropriate supervision, especially during activities that could increase the risk of falls. On the day of the incident, the RNA took the resident outside in a wheelchair and left them unsupervised on the patio. The RNA did not inform other staff members of the resident's location, and the nursing station was unstaffed at the time. The resident was later found unresponsive on the ground outside, having sustained a major head injury. The resident was transported to an acute care hospital, experienced a decline in condition, and subsequently died. Multiple staff interviews confirmed that the resident required total supervision due to their cognitive and physical impairments, and that the patio area could not be fully visualized or monitored from the nursing stations. Staff members, including CNAs and nurses, stated that it was common knowledge that residents with dementia or high fall risk should not be left unsupervised, particularly in areas where they could not be easily seen or heard. The RNA acknowledged the mistake of leaving the resident alone, and other staff confirmed that proper communication and supervision protocols were not followed. The facility's Director of Nursing also confirmed that there was no method for residents on the patio to call for help, such as a call light, further contributing to the lack of supervision and safety for the resident.