Failure to Implement and Maintain 1:1 Supervision for High-Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident identified as high risk for falls. The resident, who had a history of falls, dementia with behavioral disturbance, Alzheimer's disease, and recent hip surgery, was dependent on staff for activities of daily living and used a wheelchair for mobility. After an initial unwitnessed fall in her room, nursing management recommended 1:1 supervision, but this intervention was not consistently implemented or maintained. Despite the recommendation for 1:1 supervision, staff interviews revealed confusion and lack of clarity regarding the protocol for providing such supervision. Several staff members, including CNAs and LVNs, reported that there were no actual sitters available and that the facility was not equipped to provide 1:1 care. The resident was left unsupervised at the nurses' station, where she attempted to stand, fell, and sustained a head injury and a fractured hip. Documentation and communication lapses were evident, as not all staff were aware of the 1:1 supervision requirement, and the care plan was not promptly updated to reflect the new intervention. The failure to implement and maintain the recommended 1:1 supervision placed the resident at risk for significant injury. The resident's responsible party had repeatedly requested closer monitoring, but no effective supervision plan was put in place. The lack of clear protocols, insufficient staffing, and inadequate communication among staff contributed to the resident's subsequent fall and injury.