Failure to Supervise High Fall-Risk Resident During Bathroom Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of fall-prevention interventions for a resident with a high risk of falls and a history of multiple falls. The resident, admitted in June 2024, had diagnoses including depression, dysphagia, major depressive disorder, UTI, dementia, and a nondisplaced fracture of the lateral malleolus, and had fallen five times in the prior four months. A fall risk assessment identified the resident as at risk for falls, and the care plan effective October 30, 2025, documented that the resident was at risk for falls, sometimes self-transferred, and required chair and bed alarms to alert staff of unplanned movement, as well as oversight and assistance with transfers. On December 8, 2025, a surveyor observed the resident transferring independently from a wheelchair to the toilet while the chair alarm was sounding; a CNA entered, told the resident she was not supposed to get up alone, then turned off the alarm, closed the bedroom door, and left the resident alone in the bathroom. The next day, another CNA stated that this resident should not be left alone in the bathroom and that the resident does not always remember to use the call light. The facility’s fall prevention policy required interventions for residents assessed at risk for falls to be implemented and documented in the plan of care. These observations, interviews, and record reviews show that staff did not follow the resident’s care plan and the facility’s fall prevention policy by leaving a high fall-risk resident unattended in the bathroom after silencing the chair alarm, despite the resident’s documented history of falls, cognitive impairment, and need for supervised transfers.
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