Failure to Provide Adequate Supervision During Toileting Results in Resident Fall and Death
Penalty
Summary
Facility staff failed to provide adequate supervision to prevent an accident for a resident with significant physical and cognitive impairments. The resident, who had diagnoses including acute kidney failure, chronic obstructive pulmonary disease, unsteadiness on feet, and chronic congestive heart failure, was assessed as dependent for toileting hygiene and required supervision or touching assistance for transfers. Despite these needs, the resident was left unattended in the bathroom during toileting after requesting privacy, with the CNA stepping out and closing the bathroom door but remaining in the room. Shortly after, a noise was heard, and the resident was found on the bathroom floor, unresponsive, with a head injury and blood present. The resident was taking Apixaban for atrial fibrillation, which increases the risk of bleeding. The care plan and therapy evaluations indicated the resident required at least supervision or hands-on assistance for toileting and transfers, and the facility's fall policy required that residents not be moved until a nurse completed an assessment. However, after the fall, the resident was moved from the bathroom floor to the bed using a Hoyer lift by two staff members before a full assessment was completed. The charge nurse did not direct this action and did not perform or document an assessment due to being emotionally affected by the incident. Interviews with facility staff, including the nurse practitioner, LPN, and rehab manager, confirmed that the resident's functional abilities required supervision during toileting and transfers. Documentation and staff statements revealed that the required level of supervision was not provided, and the resident was left alone despite being dependent for toileting hygiene. The lack of adequate supervision and failure to follow established protocols directly contributed to the resident's unwitnessed fall and subsequent death.