Failure to Provide Adequate Supervision and Assistance Resulting in Major Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary assistance with activities of daily living and adequate supervision to prevent an accident for a resident with dementia, muscle weakness, hypertension, and a history of falls. The resident was assessed as moderately cognitively intact and required staff assistance for ADLs, including ambulation with a roller walker. Despite this, the resident was found on the floor of a locked dementia dining/activity room without her roller walker present, having attempted to ambulate by pushing a wheelchair while wearing slipper socks. Staff did not witness the fall, and the resident reported her legs became tangled as she tried to walk without the proper assistive device. Following this incident, the resident's care plan and physician orders were updated to require assistance of two staff with a roller walker for all transfers and ambulation. However, a subsequent event occurred when a nurse aide assisted the resident from bed to a standing position without the roller walker present. The aide stood the resident up alone, and the resident leaned forward, fell into the wall, and sustained a major head injury. The aide admitted she was aware the resident used a roller walker for transfers and ambulation but did not have the device in the room at the time and could not recall if she had reviewed the electronic Kardex for current care needs prior to providing care. As a result of the fall, the resident suffered a 7 cm scalp laceration, an acute right-sided subdural hematoma with mass effect and midline shift, and additional injuries, requiring hospitalization and intensive care. The resident's condition continued to decline, leading to hospice care and eventual death. The deficiency was identified through review of clinical records, facility policy, investigative documentation, and staff and resident interviews, confirming that the facility did not ensure necessary assistance and supervision to prevent accidents as required.