Failure to Provide Adequate Supervision in Dining Room Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure effective supervision and monitoring of residents in the dining room, resulting in an accident involving a resident assessed to be at risk for falls. The resident, who had multiple diagnoses including chronic hepatic failure, hepatic encephalopathy, Alzheimer's disease, dementia, and impaired mobility, was left unsupervised in the dining room after lunch. Staff interviews revealed that there was no clear protocol requiring staff to remain in the dining room for supervision, and the LPN assigned to monitor the area was seated at the nurse station, unable to maintain visual supervision of the resident. The resident was found on the floor in the dining room by another staff member, with no staff present in the room at the time of the fall. The resident was alert but in pain and was subsequently sent to the hospital, where she was diagnosed with a right femoral neck fracture. The care plan for this resident identified her as a fall risk, with interventions including supervision and removal from common areas after meals, but these interventions were not followed at the time of the incident. Staff interviews indicated a lack of communication regarding the resident's fall risk status, and the LPN monitoring the dining room was not informed of the resident's specific needs. The facility's fall management policy emphasized proactive identification and supervision of residents at risk for falls, but this policy was not effectively implemented, leading to the unwitnessed fall and injury.