Failure to Provide Supervision During Toileting Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Alzheimer's disease, abnormal gait, chronic pain, and a history of falls was left unsupervised on a bedside commode. The resident was dependent on two staff members for all activities of daily living and was unable to make her needs known or use a call light. Despite these needs, the resident was left alone on the commode after a shift change, with staff only nearby outside the room and not within arm's reach. The incident was discovered when a registered nurse heard a loud noise and found the resident lying on the floor in front of the commode. The resident sustained a closed comminuted fracture of the left patella and a closed head injury, as confirmed by hospital records. Interviews with staff and the resident's guardian confirmed that the resident should not have been left unattended due to her cognitive and physical limitations, and that her care plan required staff to anticipate her needs and provide safety and comfort. Facility documentation, including the fall risk assessment and care plan, indicated the resident was at high risk for falls, had poor safety awareness, and required staff assistance for toileting. The facility's ADL policy also required appropriate support for residents unable to carry out activities independently. The failure to provide direct supervision during toileting led to the resident's unwitnessed fall and subsequent injuries.