Failure to Provide Adequate Supervision During Ambulation Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when the facility failed to provide proper supervision during ambulation for a resident with severe cognitive impairment and a high risk for falls. The resident had multiple diagnoses, including unsteadiness on feet, dementia, and a history of fractures. The care plan and assessments indicated that the resident was dependent for mobility, required maximum assistance from two staff members, and was not safe to ambulate or stand unassisted. Despite these documented needs, the resident was left standing in the hallway while a CNA briefly left to retrieve a walker, during which time the resident fell and sustained a comminuted fracture to the right arm and elbow. Interviews with staff confirmed that the resident was unsteady, impulsive, and should not have been left alone while standing or walking. The CNA involved stated that he attempted to get the resident to sit back in the wheelchair and then moved a few feet away to get the walker, at which point the resident stumbled and fell into the handrail. Other staff, including LPNs, the DON, and the facility administrator, all acknowledged that the resident required continuous supervision and should not have been left unassisted during ambulation or while standing. The facility's fall management policy required individualized interventions and supervision for residents at high risk for falls, including the use of assistive devices and staff assistance as necessary. The failure to follow these protocols and provide adequate supervision directly resulted in the resident's fall and subsequent injury. Documentation and staff interviews consistently indicated that the resident's needs for supervision were well known but not adhered to at the time of the incident.