Failure to Consistently Implement Supervision Interventions for High-Risk Resident
Penalty
Summary
A resident with severe cognitive impairment, dementia, epilepsy, and anxiety was identified as being at risk for falls and elopement, requiring continual supervision during ambulation according to their care plan and resident profile. On the evening in question, the resident was able to leave their assigned unit undetected by staff, walk to the main entrance, open the door, and subsequently fall, resulting in a pelvic fracture. The facility's policy required a comprehensive, person-centered care plan to be developed and implemented for each resident, addressing all identified needs. Multiple staff interviews revealed that although the resident's need for continual supervision was documented and known, supervision was not consistently maintained. Certified Nurse Aides (CNAs) on duty were aware of the resident's fall risk and supervision requirements, but supervision was interrupted when staff attended to other residents. There was a lack of clear handoff or assurance that the resident remained in the line of sight, leading to the resident leaving the unit without staff knowledge. The Director of Nursing and other staff confirmed that the resident should have been under continual supervision and that staff should always know the resident's whereabouts. The failure to maintain required supervision directly resulted in the resident's unsupervised ambulation, exit from the unit, and subsequent fall and injury. The deficiency was attributed to staff not consistently implementing and following the care plan interventions as outlined for the resident.