Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Alzheimer's disease, dementia, and generalized muscle weakness, who was identified as a high fall risk, was left unsupervised while sitting on the edge of the bed. The resident's care plan and physician orders required staff assistance for transfers due to confusion, deconditioning, and poor balance. Despite these directives and a history of previous falls when attempting to stand without help, the resident was left sitting at the edge of the bed while the nurse aide (NA) turned away to address the roommate's repeated calls for assistance. During this time, the NA had her back to the resident and was not in a position to intervene when the resident leaned forward and fell, striking their head on the floor. The fall resulted in a laceration above the left eyebrow that required seven stitches, as well as additional bruising and pain. Staff interviews confirmed that the resident was known to be impulsive and at risk for falls, and that the NA should not have left the resident unsupervised on the edge of the bed. Facility documentation and staff interviews further indicated that the NA could have used the call light to request additional assistance rather than leaving the resident's side. The facility's fall prevention policy directed staff to reduce resident fall risk factors, but this was not followed in this instance, directly leading to the resident's fall and injury.