Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate interventions to prevent a fall with injury for a resident with severe cognitive impairment and high fall risk. The resident, who had diagnoses including dementia with psychotic disturbance, syncope, difficulty walking, and a history of falls, was observed ambulating in the hallway using a bedside tray table instead of their prescribed walker. An activity aide intercepted the resident, instructed them to hold onto the handrail, and left to return the tray table to the resident's room, leaving the resident unsupervised. While the aide was away, the resident walked away from the handrail, fell, and sustained significant injuries, including facial fractures, a left radius fracture, and contusions. The resident was found lying face down in a pool of blood and was subsequently transported to the hospital for treatment, where they required intensive care and pain management. The resident's care plan had identified them as a high fall risk, requiring supervision and the use of an assistive device (walker) for ambulation, and staff were aware of the resident's tendency to walk without their device and need for frequent redirection. Interviews with facility staff confirmed that the aide did not remain with the resident or provide hands-on assistance, despite the resident's known cognitive impairment and poor safety awareness. Facility policy required adequate supervision based on individual assessed needs, particularly for residents at high risk for falls. The failure to provide direct supervision and ensure the resident used their prescribed assistive device directly contributed to the fall and resulting injuries.