Failure to Provide Adequate Supervision to Prevent Accidents
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents with severe cognitive impairment and high fall risk. In one incident, a resident with dementia and a history of agitation and restlessness was left unsupervised in the dining room when the assigned CNA left to answer a call bell. The resident, who had a documented care plan requiring supervision in the dining area, was found on the floor with abrasions and swelling after falling from their wheelchair. The CNA assigned to monitor the dining room was not present at the time of the fall, and the resident was unable to recall the event due to impaired cognition. Another resident, also with severe cognitive impairment and high fall risk, experienced multiple falls. In one case, the resident was left unattended in the bathroom by a CNA who left to retrieve an incontinent brief. Upon return, the CNA found the resident on the bathroom floor; the resident reported hitting their head and was later diagnosed with an acute subdural hematoma at the hospital. The care plan for this resident required extensive assistance with toileting, but the CNA did not remain with the resident as required. In a separate incident, the same resident was found on the dining room floor after being left unsupervised while the assigned CNA was outside the dining room arranging a linen cart. The resident was again transferred to the hospital for evaluation of a head injury. Facility policies required staff supervision in common areas such as the dining room and specified that CNAs assigned to these areas must actively monitor residents to prevent falls and injuries. Despite these policies and individualized care plans indicating the need for supervision, staff failed to maintain required supervision, resulting in unwitnessed falls and injuries for both residents. Interviews with staff and administration confirmed that supervision lapses occurred, and that staff did not follow established protocols for monitoring high-risk residents.