Failure to Provide Supervision and Follow Care Plans Leads to Resident Falls
Penalty
Summary
Staff failed to provide adequate supervision and accident prevention interventions as outlined in residents' care plans, resulting in two separate incidents involving falls. In one case, a resident with severe cognitive impairment, repeated falls, progressive supranuclear ophthalmoplegia, dementia, and a history of aspiration risk was left unsupervised in the dining room. Despite multiple prior falls in the same location and care plan interventions specifying that the resident should not be left alone, staff left the resident unattended while assisting others. The resident was subsequently found face down on the floor with significant facial injuries, including multiple facial fractures and a comminuted nasal bone fracture. The care plan had been updated after previous incidents to require supervision in the dining room, but this intervention was not followed at the time of the fall. Interviews with staff revealed that the staff member assigned to supervise the dining room did not remain with the resident as required, citing competing care needs elsewhere in the facility. The daily staffing assignment sheet identified who was responsible for dining room supervision, but staff often did not adhere to these assignments. The medication aide and nurse confirmed that the resident should not have been left unsupervised, especially given his swallowing difficulties and risk for aspiration. The director of nursing acknowledged that the care plan intervention for dining room supervision was not followed at the time of the incident. In a separate incident, another resident with Parkinson's disease, weakness, and abnormal gait was being transferred using a sit-to-stand mechanical lift. The care plan specified that two staff members were required for transfers with this device due to the resident's instability. However, only one CNA performed the transfer, and the resident's hands slipped from the handlebars, resulting in a fall to the floor. The CNA was unaware of the updated care plan requirement for two-person assistance. Both the nurse and the CNA confirmed that the care plan was not followed, and the director of nursing agreed that this failure placed the resident's safety at risk.