Failure to Prevent Accident Hazard and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified when a resident with dementia and hypertension experienced an unwitnessed fall in the Love 2 Lounge. The resident was found on the floor in front of her wheelchair in a semi-Fowler's position. Review of the clinical record and fall incident report showed that there were no predisposing environmental factors noted at the time of the fall. Multiple staff witness statements indicated that the resident was last seen in various locations after dinner, but none reported witnessing the fall or being present at the time it occurred. The resident's care plan included an intervention to assist her to her room after dinner to prevent falls, which had been initiated prior to the incident. The facility's dinner schedule indicated staggered mealtimes across different lounges, and staff statements did not confirm the resident's whereabouts at the time of the fall. The fall incident report did not include any staff witness statements confirming that the resident was still eating dinner when the fall occurred, although the Nursing Home Administrator and DON later stated that she was. The lack of adequate supervision and failure to ensure the resident was assisted to her room after dinner, as outlined in her care plan, contributed to the occurrence of the fall.