Failure to Provide Adequate Supervision Resulting in Resident Falls and Injuries
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for two residents who were identified as being at risk for accidents. Both residents had documented histories and care plans indicating fall risk, with one resident having physical limitations, weakness, and cognitive impairment, and the other having Parkinson's disease. Despite these risks, both residents experienced unwitnessed falls resulting in injuries, including localized swelling and a displaced collarbone fracture. Observations and medical records confirmed that both residents were found with significant injuries, such as swelling and discoloration to the forehead, and in one case, a saturated incontinence garment and a bed that was not in the low position as required. Staff interviews revealed that the CNA assigned to the relevant hall was repeatedly found asleep or missing from her assigned area during the night when the falls occurred. The LPN on duty reported being unable to locate the CNA several times and did not observe her performing required rounds. The facility's policy required residents to be observed approximately every two hours to ensure safety, but this was not followed. The CNA involved was later terminated for failure to adhere to facility standards. The lack of supervision and failure to follow established protocols directly contributed to the residents' falls and subsequent injuries.