Resident Left Unattended Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including chronic kidney disease, impaired mobility, and a history of falls, was left unattended sitting on the side of the bed while preparing for dialysis. The resident required one-person assistance with transfers and ambulation, had a documented fear of falling, and was identified as being at high risk for falls due to factors such as medication effects, impaired vision, unsteady gait, and pain. The care plan specifically included interventions such as not leaving the resident unattended in the bathroom or at the bedside, using a Hoyer lift for transfers, and keeping the call light within reach. Despite these documented interventions, the resident was left alone by a CNA, resulting in the resident slipping off the bed and being found on the floor between the bed and dialysis chair with two superficial skin tears. The incident was confirmed through record review, fall investigation, and interview with the DON, who verified that the resident was left unsupervised, contrary to the care plan and facility policy. The facility's fall management policy required identification of hazards and implementation of interventions to minimize falls, which was not followed in this instance.