Failure to Provide Adequate Supervision Resulting in Resident Fall and Death
Penalty
Summary
A deficiency occurred when a resident with significant medical and cognitive impairments was left unsupervised outdoors, resulting in a fall that led to hospitalization and subsequent death. The resident had a history of hemiplegia, hemiparesis, aphasia, impaired vision, cognitive dysfunction, and was assessed as being at high risk for falls. Care plans and assessments indicated the need for supervision, cues, and fall prevention interventions due to the resident's impaired mobility, cognition, and vision, as well as a history of falls and other risk factors. Despite these documented needs, the resident was able to access the outdoor patio area alone and without supervision. Staff interviews confirmed that the resident frequently went outside by himself, and on the day of the incident, no staff were present to supervise him in the patio area. The resident was found on the ground with his wheelchair tipped backwards, having struck his head on the concrete. Staff acknowledged that supervision was required, especially when the resident was outside, but no evidence was found that supervision was provided at the time of the fall. Facility policies required individualized supervision and interventions based on assessed risks, including fall prevention for high-risk residents. However, the facility failed to implement these interventions, as there was no documentation or evidence that the resident was considered safe to be alone in the patio, nor were frequent checks or supervision provided. This lack of supervision directly contributed to the resident's unwitnessed fall and subsequent fatal injury.