Failure to Provide Adequate Supervision During Ambulation Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of repeated falls, and a recent hip fracture was not provided with adequate supervision during ambulation. The resident required supervision or stand-by assistance with a rolling walker, as documented in the care plan, MDS, and physical therapy discharge summary. On the day of the incident, a nursing assistant walked ahead of the resident, leaving the resident to ambulate alone with a walker. The resident let go of the walker, fell backwards, and subsequently suffered a hip fracture after attempting to get up and being struck by a door. Staff interviews revealed that the nursing assistant believed the resident was independent with walking, contrary to the documented requirements for supervision and assistance. The Director of Rehabilitation confirmed that the resident was not independent and required staff to be within arm's length during ambulation. The Director of Nursing also stated that staff are expected to follow physical therapy recommendations and the care plan, but was unable to provide evidence that adequate supervision was provided at the time of the incident.