Failure to Provide Adequate Supervision Resulting in Resident Fall and Major Injury
Penalty
Summary
A non-ambulatory resident with severe cognitive impairment, including a BIMS score of 6/15 and diagnoses of non-Alzheimer's dementia, diabetes mellitus, and paroxysmal atrial fibrillation, was dependent on staff for transfers and required a wheelchair for mobility. The resident had a documented history of attempting to self-transfer and had recently exhibited increased behaviors such as agitation, delusions, and attempts to stand unassisted. The care plan identified a risk for falls related to self-transfers, but interventions for supervision were not consistently documented or communicated among staff. On the evening of the incident, the resident was left unsupervised in the dining room after dinner. Multiple staff interviews revealed that there was confusion and lack of clarity regarding the resident's required level of supervision, especially during periods of increased behavioral symptoms. Staff members were either unaware of the specific supervision needs or assumed that others were responsible for monitoring the resident. The nurse on duty was new to the facility and had not been informed of the resident's supervision requirements, while CNAs and other staff did not ensure the resident was not left alone, despite knowledge of her fall risk and recent behavioral changes. As a result, the resident attempted to stand from her wheelchair, fell, and sustained significant injuries including a head injury, nasal fractures, and cervical fractures. The incident was unwitnessed, and staff only became aware after hearing the fall. Documentation and interviews indicated that the expectation for line-of-sight or one-to-one supervision during periods of agitation or self-transfer attempts was not clearly outlined in the care plan or effectively communicated to all staff, including non-nursing personnel. This lack of adequate supervision and failure to ensure a hazard-free environment directly contributed to the resident's fall and subsequent injuries.