Failure to Adequately Supervise High-Risk Resident During Toileting Leading to Recurrent Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective fall prevention interventions for a cognitively impaired resident with incontinence and a known fall risk, resulting in two unwitnessed falls with major injuries. The resident had osteoarthritis of the knee, anxiety, and Alzheimer’s dementia, with a BIMS score of 5, was frequently incontinent of bowel and bladder, and was not on a toileting program. The resident’s care plan identified a self-care deficit related to weakness and deconditioning, with interventions including toileting and personal hygiene using a straight point cane with supervise/touching assist of one staff, and dementia-related interventions to anticipate and meet needs. The care plan also identified potential for falls due to unsteady gait, with interventions such as non-skid socks, monitoring for gait changes, and offering diversional activities including toileting and ambulating. However, the clinical record did not show a scheduled toileting or prompted voiding program to address incontinence and toileting needs. On one occasion, the resident was assisted to the bathroom by a nursing assistant, who opened the bathroom door and observed the resident place the cane in the sink. The nursing assistant, aware that the resident liked privacy, partially closed the door and turned away, after which a sound was heard and the resident was found on the floor with a head strike and painful right forearm, later diagnosed as a bicondylar intra-articular fracture of the distal humerus. The DNS stated that at the time of this first fall, the resident was care planned as a supervised assist of one for toileting and personal hygiene, meaning staff were to supervise the ADL to allow for cueing and assistance, and acknowledged that the nursing assistant did not provide constant supervision because his back was turned. Subsequent documentation noted the resident was noncompliant with transfers and was observed multiple times ambulating without assistance and not using the call light. Later, the resident was found lying on the bathroom floor on the left side after using the bathroom, complaining of severe left upper extremity pain and inability to move the arm, and was diagnosed with a left displaced comminuted fracture of the distal humerus. These events occurred despite the resident’s known cognitive impairment, incontinence, unsteady gait, and identified fall risk.
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