Failure to Provide Adequate Supervision During Toileting for High-Risk Resident
Penalty
Summary
A resident with a history of atrial fibrillation, dementia, congestive heart failure, hypotension, and a recent fall at home was admitted to the facility and identified as being at high risk for falls. The resident's care plan and assessments indicated severely impaired cognition, unsteady gait, and a need for substantial to maximal assistance with toileting and transfers. Despite these documented needs, the resident was left unsupervised on the toilet by a nurse aide, who turned away to attend to bed linens while the resident remained in the bathroom. During this period of unsupervised toileting, the resident attempted to get up from the toilet and subsequently fell. The incident was unwitnessed, but the resident was later found sitting on the floor near the bathroom door. Assessments following the fall indicated no injuries, and the resident was alert but confused. The facility's fall prevention policy required staff supervision for residents at high risk for falls, and the resident's care plan specifically called for one-person assistance during toileting and transfers. Interviews and documentation confirmed that the nurse aide did not maintain direct supervision of the resident during toileting, despite the resident's cognitive impairment and high fall risk. The failure to provide adequate supervision during a high-risk activity directly contributed to the resident's fall, constituting a deficiency in ensuring the environment was free from accident hazards and that adequate supervision was provided to prevent accidents.