Failure to Supervise Resident with Impaired Mobility and Cognition Resulting in Fall
Penalty
Summary
A deficiency occurred when a moderately cognitively impaired resident with a history of stroke, hemiplegia, hemiparesis, muscle weakness, and impaired mobility was left unsupervised outside the facility in her wheelchair. The resident required total assistance for transfers and had documented risks for falls, as well as impaired visual function and cognitive deficits. Despite these needs, the resident was left unattended after being taken outside for a cigarette, with no staff present to supervise her, even though her care plan and facility policies indicated the need for supervision. While outside, the resident was observed by a surveyor rocking back and forth in her wheelchair, moaning, and slumped in the chair, with no staff monitoring her or other residents in the area. The resident was unable to communicate her needs effectively and was not alert when approached. She subsequently leaned forward, slipped out of her wheelchair, and fell onto the concrete, sustaining abrasions to her knees, a large swelling on her forehead, and a black eye. The surveyor had to alert staff to the incident, and the resident was sent to the hospital for evaluation and treatment. Interviews with staff revealed a lack of clarity regarding the supervision requirements for the resident while outside, despite her documented need for assistance and supervision, especially during smoking. The staff member who took the resident outside did not remain with her and was unsure if supervision was necessary beyond smoking. Facility policies required direct supervision for residents with restricted privileges, such as supervised smoking, but these were not followed, resulting in the resident being left unsupervised and subsequently experiencing a fall with injury.