Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when a resident, admitted for postoperative left knee replacement rehabilitation and identified as a high fall risk due to her medical history and recent surgery, was left unattended in the bathroom and later in the shower. The facility's fall prevention policy required high-risk residents to have interventions such as supervision, routine toileting schedules, and line-of-sight monitoring. Despite these requirements, the resident experienced two unwitnessed falls: the first in the bathroom and the second in the shower after being left alone by a CNA who left to retrieve supplies. The resident's care plans and physical therapy notes indicated she required supervision or touching assistance with transfers, toileting, and bathing. Staff interviews confirmed that the resident was known to be a fall risk, wore a fall risk wristband, and had signage in her room. The CNA involved in the second fall admitted to leaving the resident alone in the shower, contrary to the care plan and facility policy, because she believed it was acceptable since the resident was scheduled for discharge that day. The CNA also acknowledged that she should have called for assistance rather than leaving the resident unsupervised. As a result of being left unattended, the resident attempted to get up on her own, fell, and sustained a left femur fracture that was deemed inoperable due to her comorbidities. The incident led to the resident being transferred to the hospital and subsequently discharged home with hospice care. The failure to consistently implement fall prevention interventions and provide adequate supervision directly resulted in a major injury for the resident.