Failure to Supervise High Fall-Risk Resident During Bedside Urinal Use
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an accident for a cognitively impaired, fall‑risk resident during bedside urinal use. The resident had Parkinson’s disease with dyskinesia, dysarthria, anarthria, generalized muscle weakness, lack of coordination, difficulty walking, anxiety disorder, impaired cognition (BIMS 11), impaired balance, unsteady gait, visual difficulty, and a documented history of falls including a prior fall with injury since admission. The care plan and physician orders identified the resident as an assist of one for ADLs and toilet transfers, with interventions including assistance for toileting at wheelchair level using a grab bar, use of simple language, reorientation as needed, and instruction to ask for assistance before transferring or ambulating. On the day of the incident, a nursing assistant (NA) entered the resident’s room when the resident requested to use a urinal. The NA assisted the resident to sit on the bedside to use the urinal. When the resident was unable to urinate, the resident requested privacy. Despite knowing the resident required assist of one for ADLs and toileting, had a history of falls, was sometimes confused, and had a history of not using the call bell, the NA pulled the privacy curtain around the bed, left the resident sitting on the bedside behind the curtain and out of her line of sight, and went to provide care to the roommate. Approximately two minutes later, the NA heard a bang, opened the curtain, and found the resident on the floor beside the bed with active bleeding from the head and the urinal on the floor. After discovering the resident on the floor, the NA briefly asked if the resident was okay and then left the resident unattended again while she walked down the hallway to notify the RN, without calling out for help or using the call bell. Subsequent nursing notes documented that the resident was found seated on the floor with a laceration to the face and active bleeding from the forehead, and that EMS was notified and the resident was transferred to the hospital, where multiple forehead lacerations were repaired with absorbable sutures. Interviews with the LPN, RN, and DON confirmed that, based on the resident’s plan of care and known fall risk, the resident should not have been left out of sight behind a privacy curtain while sitting on the bedside to use the urinal, and that the NA did not maintain appropriate supervision or immediately seek assistance while the resident was actively bleeding on the floor.
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