Failure to Provide Required Supervision Resulting in Resident Fall and Injury
Penalty
Summary
A resident with diagnoses including dementia, epilepsy, and anxiety, and with severe cognitive impairment, was identified as being at high risk for falls and elopement. The resident required continual supervision during ambulation due to poor safety awareness and a history of exit-seeking behaviors. The care plan and facility policy both specified the need for ongoing staff supervision and interventions to maintain the resident's safety. On the evening of the incident, the resident was initially supervised by a CNA in the dining room, but the CNA had to leave to care for another resident and asked a colleague to supervise the resident. The second CNA, who was familiar with the resident's needs, also had to leave to answer another call light and assumed the resident would be supervised by another staff member. During this lapse in supervision, the resident left the unit undetected, walked to the facility's main entrance, opened the door, and fell outside. The event was witnessed by the receptionist, who attempted to intervene but was unable to prevent the fall. Following the fall, the resident was found on the front steps with complaints of hip and leg pain and was subsequently transferred to the hospital, where a pelvic fracture was diagnosed. Interviews with staff and the DON confirmed that the resident required continual supervision and that staff were not aware the resident had left the unit. The facility's failure to provide the necessary level of supervision directly resulted in the resident's unsupervised exit and subsequent injury.