Failure to Maintain Continuous 1:1 Supervision for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate monitoring and supervision to prevent a fall for a resident who was assessed as high risk for falls and placed on one-to-one supervision. The resident had multiple diagnoses including rib fractures, head laceration, prior unspecified fall, muscle weakness, lack of coordination, and unspecified dementia with moderate cognitive impairment (BIMS 12/15). The resident used a wheelchair, had impaired upper extremity range of motion, and was dependent on staff for transfers. Prior to the cited event, the resident had a history of falls, including an unwitnessed fall where the resident reported bumping their head and another unwitnessed fall in the bathroom resulting in a head hematoma and laceration, after which the resident’s fall risk score increased and one-to-one supervision was initiated. On the date of the incident, the resident was on one-to-one monitoring during the 3:00 PM–11:00 PM shift. The CNA assigned as the one-to-one monitor stated that she was responsible for remaining with the resident at all times unless relieved, consistent with facility expectations. Near the end of her shift, this CNA reported informing an LPN that the resident required one-to-one monitoring and stated that the LPN then asked another CNA to watch the resident, although she could not identify that CNA. The unit manager and DON both stated that a resident on one-to-one supervision should always have a staff member with them and that supervision should not be discontinued until another staff member confirms taking responsibility, as required by the facility’s continuous 1:1 supervision policy. Around the time of shift change, documentation and staff statements showed a gap in clearly assigned supervision. The RN’s incident report and handwritten statement indicated that the resident’s one-to-one monitor had left and that the RN was unsure when the one-to-one and the resident separated or whether the resident had been placed in the care of the LPN. The LPN’s written statement indicated that no one spoke with him about the resident’s care and he denied assuming responsibility or witnessing the fall. Another CNA reported clocking in shortly after 11:00 PM, seeing the resident in a wheelchair across from the nurse’s station, and then observing the resident stand and walk, with the wheelchair spinning and the resident striking their face and arm before the CNA could reach them; this CNA did not state that she had been assigned as the one-to-one monitor. The resident sustained a skin tear to the arm and later was noted to have a forehead bruise and new-onset aphasia, and was subsequently admitted to the hospital with a subdural hematoma. The DON acknowledged that assignment sheets did not identify who was assigned as the resident’s one-to-one monitor for the 11:00 PM–7:00 AM shift, demonstrating that the facility did not ensure continuous, clearly assigned one-to-one supervision as required by its policy.
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