Failure to Provide Required Supervision During Toileting Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, vascular dementia with behavioral disturbances, Parkinson's disease, and PTSD was left unattended in the bathroom during toileting, contrary to their individualized care plan. The care plan and Kardex specifically required staff to remain with the resident inside the bathroom during toileting due to their high risk for falls. On the day of the incident, a certified nurse aide assisted the resident onto the toilet, noticed incontinence, and left the bathroom to retrieve clean linens, leaving the resident alone for less than two minutes. During the aide's absence, the resident attempted to self-ambulate and fell, resulting in a left hip fracture with displacement and a complex comminuted fracture of the intertrochanteric femur. The resident was found on the floor in the bathroom doorway and subsequently required surgical intervention. Multiple staff interviews confirmed that the aide had not reviewed the resident's care plan or Kardex prior to providing care, despite facility policy and expectations that all staff review and follow individualized care plans before initiating care. The incident was identified as a break in the resident's plan of care, as confirmed by the DON, medical director, and other facility staff. The failure to provide adequate supervision as outlined in the care plan directly led to the resident's fall and injury. The event was determined to have caused actual harm to the resident, though it was not classified as Immediate Jeopardy.