Failure to Provide Adequate 1:1 Supervision Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a significant history of falls, traumatic brain injury, and cognitive impairment did not receive adequate supervision as required by their care plan. The resident was on 1:1 supervision due to agitation, unsteady gait, and a recent subdural hematoma, with interventions in place such as a low bed, fall mats, and a helmet. Despite these measures, the assigned CNA responsible for 1:1 supervision fell asleep while on duty, leaving the resident unsupervised. During the period of unsupervised care, the resident was able to get up and subsequently fell. The incident was initially reported by the CNA as an assisted transfer where the resident sat on the floor, but later investigation and interviews revealed that the CNA had dozed off and was not truthful in the initial account. The resident was found on the floor, and the event was later classified as an unwitnessed fall due to the lack of supervision. The resident was assessed and sent to the hospital for evaluation, given his prior history of head injury and the unwitnessed nature of the fall. Interviews with staff confirmed that 1:1 supervision required the staff member to always have the resident in eyesight and remain within arm's reach, and that sleeping while on duty was not permitted. The CNA admitted to falling asleep, and staff interviews corroborated that the resident was at high risk for falls and required constant monitoring. The facility's failure to ensure the CNA remained awake and provided the necessary supervision directly led to the resident's fall while under 1:1 supervision.