Failure to Provide Adequate Supervision for High-Risk Resident Resulting in Unwitnessed Fall
Penalty
Summary
The facility failed to provide sufficient nursing staff to maintain adequate supervision for a resident identified as a wanderer and at high risk for falls. The resident, an elderly female with multiple diagnoses including dementia, atrial fibrillation, and osteoarthritis, required hourly visual checks and wore a wander bracelet due to her high risk of elopement. Despite these interventions, the resident was able to leave her bed and room multiple times during the night, ultimately wandering outside onto the patio unsupervised, where she sustained an unwitnessed fall resulting in a laceration above her left eye that required hospital treatment and sutures. Review of records and staff interviews revealed that on the night of the incident, the certified nursing assistant (CNA) assigned to the resident was also tasked with being a 1:1 sitter for another high fall risk resident in a different room for several hours, leaving the original assignment unattended. The remaining CNA attempted to monitor both assignments but was also responsible for a large number of residents. Staff reported that during the night shift, there were fewer personnel available compared to the day shift, making it more difficult to provide adequate supervision for residents with high acuity and wandering behaviors. The resident's care plan included interventions such as a low bed, visual checks, and proximity to the nursing station, but no 1:1 sitter was assigned. Interviews with staff, including the charge nurse, director of staff development, and assistant director of nursing, confirmed that the resident was not identified as needing a sitter and that staffing assignments were adjusted due to a last-minute call-off. The facility's policy required adequate staffing to meet resident needs, but on the night in question, the combination of high resident acuity, staff reassignments, and reduced night shift staffing contributed to the failure to provide the necessary supervision, resulting in the resident's unsupervised exit and subsequent fall.