Failure to Maintain Required 1:1 Supervision Resulting in Resident Fall Down Stairwell
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a newly admitted, cognitively impaired resident who had an active order for 1:1 supervision and fall precautions. The resident had diagnoses including traumatic brain injury, impulse disorder, generalized anxiety disorder, polyneuropathy, and a healing clavicle fracture, and had a fall risk assessment score of 10 indicating risk for falls. Nursing documentation noted the resident had multiple trips to the bathroom with watery stools, an unsteady gait, confusion, restlessness, and agitation, and was on hourly rounds while staff awaited implementation of 1:1 supervision. Despite an existing physician order for 1:1 supervision to ensure safety and support cognitive recovery, the assigned CNA left the resident’s bedside to walk two doors down the hall to ask another staff member about break coverage after providing the resident with water and covering him in bed. The facility’s policy and staff interviews indicated that 1:1 supervision required the sitter to remain at the bedside at all times, within one arm’s length of the resident, and to use the call light to request breaks rather than leaving the room. During the period the resident was left unsupervised, the resident exited the unit through a nearby emergency exit door located approximately 30 feet from the resident’s room. The resident descended a flight of eight stairs and was found by staff sitting at the bottom of the steps after the exit door alarm sounded. On assessment, the resident had abrasions to the right side of the forehead, the bridge of the nose, the right hand palm, and the right hand fourth digit. The incident occurred in the context of the facility’s own policy defining neglect to include inadequate supervision when a victim is left alone despite a caregiver being present but not providing necessary supervision. Interviews with the risk manager, RN leader, administrator, and DON confirmed that the sitter should not have left the resident alone and that the resident’s restlessness, impulsiveness, and psychiatric/TBI history made continuous supervision necessary under the ordered 1:1 precautions.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.