Failure to Supervise High-Risk Dementia Resident During Toileting Resulting in Fall With Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident with dementia who required staff assistance for toileting and ambulation. The resident had multiple diagnoses including dementia, prior fall with fractured femur, stroke, anxiety, history of falls, atrial fibrillation, and was on Apixaban, an anticoagulant. The care plan and fall risk evaluation identified the resident as high risk for falls due to confusion, limited mobility, incontinence, psychotropic medication use, seizure disorder, vision impairment, and multiple prior falls. The MDS documented moderately impaired cognition, frequent bladder incontinence, occasional bowel incontinence, and a need for extensive assistance with transfers, toileting, and personal hygiene. On the date of the incident, a nurse aide toileted the resident and then left the resident alone in the bathroom to obtain a brief, despite knowing the resident had a habit of getting up unassisted, wandered at times, was at risk for falls, and should not be left alone in the bathroom. The aide reported that other staff were busy, so she left the resident unattended on the toilet with a wheelchair present while she went to get supplies. When she returned, the resident was found on the floor between the bed and dresser, bleeding from the mouth and clutching underwear. Nursing staff were called to assess the resident, who was observed face down on the floor, bleeding from the lips but awake and alert at baseline. The resident was transferred to the emergency room, where evaluation documented a lower lip laceration requiring Dermabond, facial contusion, hematoma, loose upper teeth, and headache, with a CT scan showing no acute findings. Subsequent nursing documentation noted facial contusions, subluxation of a tooth, ecchymosis and swelling to the lip, chin, neck, and below the eye, and later fading bruising with mild pain but ability to chew and drink. Interviews with therapy staff, nursing leadership, and nursing staff confirmed that the resident required assistance of one for toileting, had dementia, was at high risk for falls, and should not have been left unattended in the bathroom. The facility’s fall prevention policy stated that residents at high risk for falls would have interventions initiated to prevent falls, but in this case the resident was left unsupervised, leading to a fall with injury.
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