Failure to Safely Supervise High-Risk Resident During Ambulation
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise and safely assist a resident with known fall risk and ambulation difficulties, resulting in a left hip fracture. The resident had diagnoses including Alzheimer’s dementia, unsteadiness of feet, weakness, and rheumatoid arthritis. A recent MDS indicated she was unable to complete the Brief Interview for Mental Status and had both short- and long-term memory problems. A restorative note documented that staff on the locked memory care unit and the resident’s husband had observed that when she was tired or not walking well, she tended to walk too far behind her rollator, and that the rollator sometimes "gets away from her." Staff interviews, including with the DON and nursing staff, confirmed that the resident required assistance with ambulation and the use of a gait belt for safety. On the day of the incident, a CNA was taking the resident to the toilet shortly after lunch while the other CNA on the unit was in a room providing care and the nurse assigned to the memory care unit was off the unit performing wound care on other units. The CNA observed that the resident’s walker was getting away from her, with the resident’s buttocks sticking out and her arms stretched out toward the walker. The CNA reported that the resident appeared confused and did not understand coaching to move toward the walker. Believing the resident would not make it safely to the bathroom, the CNA decided to step away a few steps to get a chair, during which time the resident fell. The CNA acknowledged that a gait belt was not in use and that she left the resident’s side despite recognizing the resident’s compromised positioning and confusion. Following the fall, the nurse responded and observed the resident lying on her back in the common area with the left lower extremity bent at the knee and externally rotated, and the area was immobilized. The nurse noted that the resident, who typically did not have pain, was experiencing significant pain, especially when the left leg was touched, and she believed the leg was broken based on the pain and rotation. The resident was subsequently admitted to the hospital with a left hip fracture. The facility’s Safe Resident Handling/Transfers policy required proper hands-on assistance during ambulation and specified that residents should never be left unsupported when balance is compromised or when the resident stops walking. Staff interviews, including with the DON and other CNAs and RNs, consistently indicated that the resident required assistance with ambulation and a gait belt, and that the CNA should not have left the resident unsupported but should have called for assistance and, if needed, used a gait belt to lower her to the floor.
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