Failure to Provide Required Supervision and Timely Care After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe rheumatoid arthritis, osteoarthritis, morbid obesity, and a recent decline in cognition was left unattended with a meal tray placed out of reach. The resident had documented needs for 1:1 feeding assistance due to their inability to feed themselves and significant mobility limitations, including a requirement for two-person assistance with transfers and being non-ambulatory. Despite these documented needs and orders, the resident was left alone in their room, sitting on the side of the bed, and attempted to reach for their meal tray, resulting in a fall from the bed. Following the fall, the resident complained of pain in the left leg, but there was a delay in obtaining diagnostic x-rays. Although a STAT x-ray was ordered the day after the fall, the imaging was not completed until approximately 30 hours after the incident. The x-ray revealed an acute comminuted fracture of the left distal femur, which required hospitalization and surgery. The resident subsequently died from complications related to the fracture. Interviews with facility staff and review of the resident's care plan and medical record revealed that the required 1:1 feeding assistance was not provided at the time of the incident. The care plan and Kardex lacked specific instructions regarding bed mobility and 1:1 assistance, and staff confirmed that no one was present to assist the resident with eating when the fall occurred. Facility policies on fall risk management and meal assistance were not followed, as interventions to prevent falls and ensure safe feeding were not implemented according to the resident's assessed needs.