Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement effective care plan interventions for a resident with multiple high-risk diagnoses, including delirium, dementia, and impaired mobility. The resident was identified as high risk for falls, with a fall risk score of 22.0, and had a recent history of falling. Despite care plan interventions requiring close monitoring in the common area, the resident was left unsupervised when the assigned LPN was charting at the nurse's station and two CNAs were occupied assisting another resident. During this lapse in supervision, the resident attempted to stand and walk, resulting in a fall and a right hip fracture. Staff interviews confirmed that the expectation was for high fall risk residents to be closely monitored in the common area, with staff in close proximity, not at the nurse's station. The LPN responsible for monitoring the resident was not present in the common area at the time of the fall, and staff acknowledged that the unit was understaffed to provide adequate supervision for the number of high-risk residents. The facility's fall prevention policy required identification and implementation of interventions for residents at risk for falls, but these were not effectively carried out, leading to the resident's injury.