Failure to Provide Adequate Supervision and Lighting Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure sufficient lighting in a resident's bedroom and did not provide adequate supervision for a resident with dementia who was known to be restless and at high risk for falls. The resident had a documented history of falls, severe cognitive impairment, and behavioral disturbances, including agitation and restlessness. The care plan included interventions such as walking with the resident when restless and providing adequate lighting, but these were not consistently implemented. On the night of the incident, the resident was observed to be agitated and repeatedly attempting to stand and walk independently. Staff had previously walked with the resident using a walker and gait belt, but later put the resident to bed with the bedroom lights off. The resident was left unsupervised, and staff did not continue frequent safety checks, despite the resident's high fall risk and recent history of falls. The resident was later found on the floor in the dark room, with injuries including a hematoma to the head and multiple skin tears, and was entangled in television cords. Interviews with staff revealed that the decision to put the resident to bed was made despite ongoing restlessness, and that agency staff felt their input regarding the resident's care would not be well received. The facility's own policy required individualized fall prevention interventions and ongoing monitoring, but these were not adequately followed. The resident ultimately died from complications related to the unwitnessed fall, as confirmed by the county coroner.