Failure to Provide Adequate Supervision and Accident Hazard Prevention
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, impaired thought process, and multiple medical conditions including COPD, diabetes, and peripheral vascular disease, was left unsupervised in their room. The resident required significant assistance with mobility and activities of daily living, and was assessed as a low fall risk on admission, with interventions such as call light within reach and partial side rails. Despite these measures, the resident's room was located behind the nurse's station and out of staff view, and there was no documented evidence of specific supervision or monitoring for safety. On the day of the incident, the resident was left alone in their wheelchair for approximately thirty to forty minutes, during which time they experienced an unwitnessed fall resulting in a laceration and bruising. Interviews with staff revealed inconsistent assessments of the resident's fall risk and safety needs. While some staff considered the resident a fall risk and stated that such residents are typically kept near the nurse's station for observation, the resident was left alone in their room at the request of their representatives. The care plan and assessments did not include enhanced supervision or monitoring, and staff relied on standard interventions. The lack of adequate supervision and failure to anticipate the resident's safety needs directly contributed to the incident.