Failure to Provide Adequate Supervision for High-Risk Resident Resulting in Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident diagnosed with Lewy Body Dementia, resulting in a fall and acute left hip fracture. The resident had a documented history of severe cognitive impairment, wandering, and previous falls, and was identified as high risk for both falls and elopement. The care plan specified the need for frequent monitoring, with staff and policy indicating that high-risk residents should be checked every 15 minutes. However, on the day of the incident, documentation showed the resident was last repositioned at 8:22 AM, with the fall occurring at 3:50 PM, and there was no evidence of the required frequent checks being performed or documented. Interviews with staff confirmed that the resident frequently got up without assistance and that the expectation was for high-risk residents to be checked every 15 minutes. Despite this, staff were unable to provide documentation that these checks occurred as required. The resident was found by a CNA after losing balance and falling, and subsequent medical evaluation confirmed a left hip fracture. The facility's failure to implement and document the required supervision and monitoring directly led to the resident's fall and injury.