Failure to Supervise High Fall-Risk Resident and Document Wheelchair Fall Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance devices to prevent accidents for a resident identified as high risk for falls. The resident had diagnoses including constipation, chronic pain syndrome, a history of falling, and a Minimum Data Set showing moderately impaired cognition. A physician’s order dated 11/11/2025 allowed the resident to be out of bed to a standard wheelchair with bilateral elevating leg rests and required partial to moderate assistance during manual transfer by one person. Despite a facility fall risk assessment policy requiring identification and documentation of fall risk factors and evaluation of conditions that may predispose residents to falls, there was no documented evidence on the Documentation Survey Report or Resident Nursing Instructions form describing how staff should supervise this resident to prevent falls. On 12/06/2025 at approximately 5:10 PM, an Occupational Therapist Assistant observed the resident sliding off a wheelchair on the third floor. The assistant reported that the resident got up independently, sat back in the wheelchair, and then slid off again, after which the assistant informed an LPN and wrote a statement left at the nursing station. There was no documented body assessment, no documentation that the physician or family were notified, and no documented facility investigation of the incident. The RN Supervisor later stated they were informed that the resident slid out of the wheelchair, asked the resident what happened, and performed a body assessment but did not document a fall assessment because there was no trauma, injuries, or skin changes, and did not inform the physician. The Director of Nursing stated they were not aware of the incident and acknowledged that the RN Supervisor should have initiated an incident report, collected staff statements, and reported the fall to the physician and the resident’s family representative.
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