Failure to Provide Adequate Supervision and Assistance Results in Resident Fall and Injuries
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate assistance to prevent an avoidable accident for a resident with severe cognitive impairment and multiple medical diagnoses, including heart failure, asthma, and respiratory failure. The resident required maximal assistance for transfers and had a care plan indicating the need for close monitoring and interventions to prevent falls. Despite these documented needs, a certified nursing assistant left the resident sitting unassisted on the side of the bed while retrieving a wheelchair from across the room. During this time, the resident fell, resulting in significant injuries including right medial and posterior orbital fractures, a laceration, and broken dentures. Interviews with staff revealed that the resident had been declining and required maximal assistance, with therapy staff indicating that two staff members were needed for transfers and that the resident was unable to follow directions. The facility's policies on fall risk management and safe lifting emphasized the need for individualized interventions and appropriate techniques to ensure resident safety. However, these protocols were not followed, leading to the resident being left unsupervised and sustaining serious injuries.