F0689

D

Inadequate Supervision for High-Risk Resident Leading to Repeated Falls and Head Injury

Greenwich, Connecticut Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

Failure to provide adequate supervision and prevent accidents occurred for a resident with metabolic encephalopathy, dementia, glioblastoma, a prior fall before admission, and severely impaired cognition (BIMS score of 5). On admission, the resident was identified as high risk for falls, required maximal assistance with toileting and transfers, and had a care plan that included ensuring the call light was within reach and use of appropriate footwear (brown leather shoes and non-skid socks) when ambulating. Despite these identified risks and interventions, the resident experienced multiple falls: on 12/19/2025 the resident was found sitting on the floor with a mid-back abrasion; on 1/7/2026 the resident was found prone on the floor, wearing regular socks, having hit the head and requiring hospital evaluation; and on 1/19/2026 the resident was again found on the floor, reporting having hit the head, with vomiting and a left ankle abrasion, and was transferred to the hospital.

The resident sustained another fall on 1/25/2026 when a NA heard a loud sound during rounds and found the resident on the floor; the resident had not called for assistance before getting up and complained of pain on the back of the head, leading to hospital transfer. Hospital findings included an acute subarachnoid hemorrhage, a subdural hemorrhage, and bifrontal contusions. Interviews and record review with the DNS and ADNS showed that after the earlier falls, the care plan was updated only to direct use of non-skid socks every shift, and no additional measures or increased supervision were identified or implemented following the fall on 1/19/2026 to prevent the subsequent fall with injury on 1/25/2026. No facility policy related to this issue was provided for surveyor review.