Failure to Supervise Resident with Dementia During Toileting Results in Fall and Injury
Penalty
Summary
A resident with a diagnosis of dementia and a known fall risk, as indicated by a BIMS score of 6 (severely impaired cognition), was dependent on staff for toileting and transfers. The resident's care plan required assistance of one staff member for these activities. On the date of the incident, a nursing assistant (NA) assisted the resident to the bathroom and left the resident sitting on the toilet for privacy, waiting outside the door. The NA was then called to assist another staff member across the hall, leaving the resident alone in the bathroom. During this time, the resident fell and was found on the bathroom floor, complaining of right hip pain and exhibiting a skin tear on the left shin. The fall was unwitnessed, and the resident was unable to provide a reliable account of the incident due to cognitive impairment. Subsequent evaluation revealed the resident had sustained a displaced right femoral neck fracture and was transferred to the hospital for further care. Interviews with facility staff, including the NA involved and the Director of Nursing, confirmed that the resident required assistance for transfers and should not have been left alone in the bathroom. The facility was unable to provide a policy regarding supervision of residents with dementia during toileting for surveyor review. The deficiency resulted from the failure to provide adequate supervision and prevent accident hazards for a resident at high risk for falls.