Resident Left Unattended After Expressing Intent to Exit Bed, Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, limited mobility, and a history of depression expressed to a Certified Nurse Aide (CNA) an intent to jump out of bed if left alone. Despite this clear verbalization of risk, the CNA left the resident unattended in their room to respond to another situation elsewhere in the facility. Upon returning, the CNA found the resident on the floor, having sustained skin tears to both upper extremities. The resident's care plan indicated a need for assistance with self-care and mobility, as well as monitoring for cognitive changes, but these interventions were not adequately followed at the time of the incident. The facility's policy required a systems approach to safety, considering both environmental hazards and individual resident risk factors. The resident's care plans documented the need for supervision and assistance due to their cognitive and physical limitations. However, the CNA did not use the call bell or seek immediate help before leaving the resident, despite the resident's explicit statement of intent to get out of bed. This failure to provide adequate supervision and to follow established safety protocols resulted in the resident's fall and subsequent injuries.