Failure to Provide Adequate Supervision During Smoking Breaks Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision during a designated smoking break, resulting in a resident with a history of falls and diabetic neuropathy sustaining significant injuries. The resident, who was cognitively intact and required supervision and touching assistance for ambulation, was attempting to navigate a ramp to the smoking area using a rolling walker. During this time, another resident with moderately impaired cognition and a history of impulsive behavior during smoke breaks was also present. The second resident, known for being impatient and having previously bumped into others with his walker, collided with the first resident, causing her to fall and sustain large skin tears and lacerations to both forearms, necessitating emergency medical care and wound specialist intervention. Multiple interviews with residents and staff confirmed that the second resident frequently rushed during smoke breaks, often bumping into others with his walker. Witnesses described the incident as the injured resident trying to move out of the way to avoid being run over, ultimately losing her balance and falling. Several other residents reported similar experiences of being bumped by the same individual during smoking breaks, with at least one other resident sustaining a skin tear as a result. Staff statements indicated that supervision during the incident was insufficient, as the supervising CNA was occupied distributing cigarettes and did not ensure all residents were safely in the smoking area before doing so. The facility's policies required supervision during smoking and interventions to address individual fall risks, but these were not effectively implemented. The care plan for the resident who fell included interventions for fall prevention, but did not address the specific risk posed by the other resident's impulsive behavior during smoke breaks. Additionally, the care plan for the resident with impulsive behavior had previously removed a focus area on his rushing during smoke breaks, despite ongoing incidents. The lack of adequate supervision and failure to implement appropriate interventions directly contributed to the accident and resulting injuries.