Failure to Provide Adequate Supervision and Safety Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and implementation of safety interventions for a resident with poor safety awareness, a history of falls, and moderate fall risk. The resident, who had severe cognitive impairment, was fully dependent on staff for activities of daily living and had a care plan requiring supervision at the nurses' station. Despite these documented needs, the resident was left in a wheelchair in the hallway, not within arm's reach or direct observation of staff. On the day of the incident, the resident attempted to stand up from her wheelchair unassisted. A CNA, who was several feet away, saw the resident trying to get up and shouted for her to stop, but was unable to reach her in time. The resident did not respond to verbal cues and fell to the floor, landing on her right side. The RN present at the nurses' station was not actively observing the resident and was also unable to intervene in time to prevent the fall. Interviews and record reviews confirmed that the staff did not provide the necessary redirection, cueing, or close supervision as outlined in the resident's care plan and the facility's policies. The facility's policies required individualized interventions and consistent implementation of safety measures for residents at risk of falls, but these were not followed, resulting in the resident's fall and subsequent transfer for further evaluation.