Failure to Supervise Resident in Dining Room Leads to Serious Injury
Penalty
Summary
The facility failed to provide adequate supervision in the dining room, resulting in an avoidable accident involving a resident with multiple psychiatric and neurological diagnoses, including generalized anxiety disorder, paranoid schizophrenia, drug-induced secondary Parkinsonism, and moderate cognitive impairment. The resident required supervision or assistance with ambulation, as documented in their functional abilities assessment. Despite these needs, the resident was left unsupervised in the dining room, where an altercation occurred after the resident took another resident's coffee, leading to a fall. Staff interviews revealed that on the day of the incident, there was no CNA assigned to the unit, and both nurses present stated that no staff were supervising the dining room. Multiple staff members described the resident as delusional, disoriented, and prone to pacing and talking to himself, with a baseline of confusion. The fall resulted in significant injuries, including a comminuted fracture of the right humerus and a nasal bone fracture, requiring surgical intervention. The incident was not witnessed by staff, and there was uncertainty among staff about which residents were present in the dining room at the time. Documentation and interviews further indicated that staff on the unit considered the residents to be independent and did not monitor them in the dining room. The facility's fall prevention policy required additional interventions after a fall, but the lack of supervision and failure to recognize the resident's need for monitoring directly contributed to the incident. The staffing assignment sheet also showed discrepancies between staff assignments and actual coverage, with a CNA denying working on the unit despite being listed as assigned.