Resident Fall Due to Inadequate Supervision and Unsafe Bed Position
Penalty
Summary
Facility staff failed to provide a safe environment for a resident with a history of cerebrovascular accident, hemiplegia, and hemiparesis, who was assessed as requiring substantial to maximal assistance for bed mobility. On the day of the incident, the resident was left unattended in bed in a high position while being cleaned. The certified nursing assistant (CNA) left the room to obtain additional supplies, leaving the resident on their side without supervision. As a result, the resident rolled off the bed, landing face down on the floor, and sustained a hematoma and an occipital condyle fracture. Clinical documentation and staff interviews confirmed that the resident's care plan identified them as being at risk for falls due to muscle weakness, poor balance, psychoactive medications, recent hospitalization, and high-risk medication use. The care plan included interventions such as placing items within reach and reminding the resident to use the call light for assistance with activities of daily living. However, the CNA did not ensure the resident's safety by either calling for assistance or gathering all necessary supplies before starting care, and left the resident in an unsafe position. Progress notes and interviews further revealed that the resident was coded as dependent for bed mobility for a significant number of shifts, and staff were expected to verify the required level of assistance before providing care. The incident occurred despite the presence of fall mats, as the bed was not in the lowest position and the resident was left unsupervised. The failure to provide adequate supervision and maintain a safe environment directly resulted in the resident's fall and injury.