Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A resident with a history of Alzheimer's disease, dementia, severe cognitive impairment, and multiple comorbidities was identified as high risk for falls, requiring staff assistance and supervision for toileting and transfers. The resident's care plan and fall risk assessments specifically indicated that the resident should not be left unattended in the restroom due to confusion, poor balance, and a history of falls. Interventions included the use of alarms, prompt response to requests for assistance, and direct staff supervision during toileting. Despite these documented precautions, the resident was left unattended on the toilet by a CNA who stepped away to respond to alarms in other rooms. The CNA reported that the resident had requested privacy and confirmed understanding of how to use the call light, so the CNA left the resident alone. During this period, the resident attempted to stand unassisted, lost balance, and fell, resulting in a hematoma to the head and a displaced subcapital femoral neck fracture. The incident was unwitnessed, and the resident was found on the floor by staff after the fall occurred. Interviews with staff and review of records confirmed that the resident was known to be impulsive and at high risk for falls, with several staff members stating that the resident should never be left alone due to her tendency to get up unassisted. The CNA involved was not aware of the specific requirement to remain with the resident during toileting and had not received adequate instruction regarding when residents should not be left unattended. The facility's fall prevention protocol was in place, but staff failed to follow the individualized interventions outlined in the resident's care plan, resulting in the resident's fall and subsequent injury.