Failure to Supervise High Fall Risk Resident Resulting in Injury
Penalty
Summary
The facility failed to provide adequate supervision and implement effective fall prevention strategies for a resident assessed as high risk for falls. The resident, who had diagnoses including end stage renal disease and atrial fibrillation, was cognitively intact but required substantial to maximal staff assistance for mobility and transfers, and was dependent on staff for chair to bed transfers. Despite documented balance deficits, decreased safety awareness, and a history of multiple unwitnessed falls from bed, the resident was repeatedly left unsupervised at the edge of the bed, contrary to care plan interventions and staff knowledge of the resident's needs. The resident experienced at least four unwitnessed falls, each time being found on the floor after being left at the edge of the bed or in bed without adequate supervision. After each fall, interventions such as ensuring the resident was not left at the edge of the bed, frequent checks, and securing the mattress were documented, but these were not consistently implemented. On one occasion, after returning from dialysis and expressing fatigue, the resident was positioned at the edge of the bed for a meal and left unattended, resulting in a fall that caused multiple fractures to the right wrist and required hospital transfer. Interviews with staff confirmed that the resident required two staff and a mechanical lift for transfers, had significant balance issues, and was not safe to be left at the edge of the bed unattended. Staff acknowledged that the resident was frequently drowsy, especially after dialysis, and that leaving the resident unsupervised at the bedside was unsafe. The Director of Nursing Services also confirmed that the resident was high risk for falls and should not have been left unattended at the edge of the bed, especially given the resident's history and condition at the time.