Failure to Supervise High Fall-Risk Resident and Ensure Access to Toileting Aids
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough fall investigation, implement fall interventions, and provide adequate supervision for a high fall-risk resident. The resident had diagnoses including encephalopathy, vascular dementia with behavioral disturbance, anemia, weakness, a history of falls, and a pacemaker, and was documented as moderately cognitively impaired. The MDS showed the resident required supervision with toileting, bathing, dressing, bed mobility, and transfers, and the fall care plan identified the resident as at risk for falls with interventions such as use of a gait belt for transfers and ensuring appropriate footwear. An incident fall assessment documented 1–2 prior falls in the past three months and intermittent confusion. On the date of the fall, nursing documentation showed the resident was found on the bathroom floor after an unwitnessed fall, barefoot and using a walker without assistance, with the call light not used. The resident sustained a forehead laceration, abrasions to the right knee and left foot, and was on blood thinners. Hospital records documented left ankle swelling, a foreign body and laceration of the left fifth finger, and a closed head injury with a hematoma to the right forehead, with the resident noted to have dementia and be a poor historian. Subsequent observations showed the resident repeatedly seated in his room with the urinal placed in the bathroom and not within reach, and the call light lying across the bed and not within the resident’s reach. The resident stated he did not know where his urinal was and that he would just get up and go to the bathroom if needed. CNAs reported hearing a thud and finding the resident on the floor on his right side, barefoot, with the walker on its side and blood on the floor from the finger injury. One CNA stated she had been instructed that the resident did not need assistance walking and that he walked independently with his walker to the bathroom and was not considered a fall risk. Another CNA, who was assigned to the resident on the morning of the fall, stated she had not checked on the resident for a few hours and that the resident got up independently and did not need staff assistance for toileting. The DON stated the resident should have had appropriate footwear and that the intervention for the fall was to place a urinal at the bedside and keep it within reach, but acknowledged she did not interview staff during the fall investigation, did not determine whether the call light was within reach, and did not determine the status of the resident’s footwear at the time of the fall, confirming the fall investigation could have been more thorough.
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