Failure to Provide Supervision Resulting in Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents with known fall risks. One resident, who had diagnoses including muscle weakness, lack of coordination, and repeated falls, experienced an unwitnessed fall in the shower after being left unattended by a CNA. The resident reported slipping while trying to get dressed after the shower, and the Assistant Director of Nursing confirmed that the CNA should not have left the resident alone. This resident had a history of falls, including incidents related to not locking walker brakes and a seizure, but the specific deficiency cited was the lack of supervision during the shower, which resulted in a fall. Another resident, with diagnoses of unspecified dementia, psychotic and mood disturbances, and a consistently high fall risk, required supervision while smoking according to assessments and care plans. Despite this, the resident was left unsupervised on the smoking patio, where she fell after her walker became caught on uneven pavement. The fall was witnessed by another resident, who reported that no staff were present at the time. The Assistant Director of Nursing confirmed that this resident was not independent with smoking and required staff supervision, which was not provided at the time of the fall.