Failure to Provide Adequate Supervision During Toileting for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when a resident, assessed as high risk for falls due to a history of right femur fracture, Alzheimer's disease, osteoporosis, and severely impaired cognition, was left unsupervised on the toilet by a CNA. The resident required maximal assistance with toileting hygiene and was dependent on staff for toilet transfers, as documented in the Minimum Data Set and care plan. Despite these documented needs, the CNA left the resident alone in the restroom to inform another resident she was assisting the high-risk resident, during which time the resident attempted to stand, fell, and sustained a forehead laceration requiring five sutures at a general acute care hospital. Interviews with facility staff, including the CNA, LVN, RN, Director of Rehabilitation, and Assistant Director of Nursing, confirmed that the resident should not have been left unattended due to cognitive deficits, poor understanding of safety measures, and toe-touch weight-bearing status following a recent femur fracture. Staff acknowledged that supervision should have been maintained, and the CNA admitted it was unsafe to leave the resident alone. The care plan for the resident lacked specific instructions regarding the type and level of assistance required during toileting, which staff indicated could lead to miscommunication and increased risk of avoidable mistakes. The facility's policy on fall management required individualized care plans and interventions for high fall risk residents, but the care plan in this case did not specify the necessary supervision or assistance. The lack of clear guidelines and staff adherence to supervision protocols directly contributed to the resident's fall and injury while using the toilet.