Failure to Adequately Supervise High-Risk Blind Resident During Bathroom Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and supervision for a newly admitted resident with known high fall risk and impaired safety awareness. The resident, an older male with diagnoses including difficulty in walking, unspecified cataract, history of falling, nontraumatic subdural hemorrhage, cerebral edema, hypertension, ADHD, and other conditions, was blind and required substantial/maximal assistance with toilet transfers per the MDS. The MDS also documented short- and long-term memory problems, yet the resident’s fall risk evaluation scored him as low risk, and there was no documented fall care plan or fall prevention interventions beyond a bed alarm. The family had informed staff upon admission that the resident required constant monitoring due to blindness. On the day of the incident, the resident had been in the facility less than 24 hours and was assigned to a CNA, with clinical students present on the unit. Earlier in the day, the CNA and a clinical student assisted the resident to the bathroom, where he urinated on the floor and was difficult to redirect, insisting he knew what he was doing. They cleaned him, dressed him, returned him to his wheelchair, and left the room. Later, during the lunch meal, the CNA directed the clinical student to assist the resident with feeding. The resident requested to go to the bathroom, and the clinical student took him there. The student then left the resident alone in the bathroom to get help to clean urine on the floor, and when staff returned, the resident was found on the bathroom floor with a puddle of urine present. The resident’s fall was unwitnessed, and he was found sitting on the bathroom floor with his head against the door. Vital signs were obtained, and no visible injuries were initially noted; the resident stated he slipped and fell while coming out of the bathroom. The DON later stated that clinical students cannot provide accurate monitoring and supervision and that proximate supervision requires facility staff to be physically present with students during direct care, but the resident had been left under the student’s care without such proximate staff supervision. The resident was subsequently sent to the hospital, where imaging showed a 7 mm subdural hemorrhage along the parieto-occipital convexity, with the report noting that in the setting of recent trauma, an acute hemorrhage could not be entirely excluded. The facility did not report the fall to authorities, citing uncertainty about whether the hemorrhage was acute and the resident’s prior brain-related history.
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