Failure to Provide Adequate Supervision and Timely Assistance Leads to Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who was at risk for falls. The resident, a male with intact cognitive ability, non-Alzheimer's disease, unsteadiness on his feet, and requiring maximum assistance for transfers, was found on the bathroom floor after attempting to transfer independently from his electric wheelchair to the toilet. The resident's care plan identified him as a fall risk due to immobility, muscle weakness, diabetes, and chronic pain, and included interventions such as keeping the call light within reach at all times. On the night of the incident, the resident reported pressing his call light to request assistance to use the bathroom but stated that staff did not respond in a timely manner. After waiting as long as he could, he attempted the transfer himself, resulting in a fall. The resident then called 911 for help, as no staff responded to his calls for assistance after the fall. Emergency medical services arrived and assisted him back into his wheelchair. At the time, both the CNA and nurse assigned to the resident's hall were on break simultaneously, leaving the resident without adequate supervision. Interviews with staff and the DON revealed that staff were not supposed to take breaks at the same time, but both the CNA and RN assigned to the resident were outside on break when the fall occurred. The DON did not initially interview the resident as part of the fall investigation and was unaware that the resident had called for help and received no response. The facility's fall management policy required identification of fall risks, planning and implementation of interventions, and thorough investigation of falls, including interviewing the resident and staff, but these steps were not fully followed in this case.