Failure to Accurately Assess and Supervise Resident Leads to Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including hemiplegia, hemiparesis following a stroke, epilepsy, muscle weakness, and difficulty walking, was not accurately assessed for fall risk and required assistance levels. The resident's assessments, including the Fall Risk Observation/Assessment and Admission/readmission Evaluation/Assessment, did not accurately reflect the resident's need for assistance with ambulation and toileting. Documentation and interviews confirmed that the resident required at least one-person assistance for transfers and toileting, and had moderate cognitive impairment. Despite these needs, staff failed to provide adequate supervision and assistance during toileting. A CNA assisted the resident into the bathroom but left the resident unsupervised after being asked to close the door and then left to answer another call light. The resident was subsequently found on the bathroom floor after an unwitnessed fall, stating that they had slid down from the commode. Interviews with the DON and DOR confirmed that the resident required one-person assistance and that staff should have remained nearby to provide the necessary support. Record reviews and staff interviews further revealed that the licensed nurse did not accurately assess the resident's fall risk or assistance needs, and seizure precautions were not properly noted. Facility policies required that residents unable to perform activities of daily living independently receive necessary services, and that fall risk factors be evaluated to minimize risk. These failures resulted in the resident experiencing an unwitnessed fall while unsupervised during toileting.