F0689

D

Failure to Adequately Supervise High-Risk Resident Leading to Unwitnessed Injury

Monticello, Iowa Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and monitoring for a resident with a known history of falls and behavioral issues. The resident had diagnoses including Alzheimer’s disease, hypertension, traumatic brain injury, and seizure disorder, and the MDS documented two or more prior falls with non‑major injury. The care plan identified the resident as a fall risk related to poor safety awareness and impaired balance, and also noted physical behaviors, behaviors directed toward others, and a risk for making false accusations. The care plan interventions included ensuring the call light was within reach, use of appropriate footwear, leaving the bathroom door ajar with the light on, and encouraging the resident to keep the door open at night to allow for more frequent staff checks. Despite these identified risks and interventions, the resident was allowed to keep his door closed with a sign instructing staff to knock before entering, and staff relied primarily on the resident’s use of the call light or yelling from the doorway rather than consistent in‑person checks.

On the night of the incident, camera footage showed that a CNA entered the resident’s room at approximately 9:36 p.m. to administer bedtime medication, after which no staff entered the room again until about 6:15 a.m. the following morning. During that interval, the resident did not activate his call light. Staff interviews confirmed that the nurse on duty did not go into the resident’s room during the shift and believed that an aide had done so, while the agency aide assigned to the hall did not actually enter the room, instead only going to the door and listening because the resident became angry when staff opened his door. This pattern of inaction resulted in a prolonged period—roughly the entire night shift—during which no staff member visually assessed the resident, despite his documented fall history, behavioral issues, and care plan direction for more frequent checks.

At approximately 6:10–6:15 a.m., a CNA entered the resident’s room for morning care and found him in bed with smeared blood on his chin and a swollen, reddened lower lip with an internal laceration, as well as abrasions on his right arm and right shin. Blood was observed on the nightstand, on the leg of the tray table, and on the floor next to it. The resident reported that an employee had come into his room and assaulted him, at various times describing the assailant as a female employee, a male employee, and later accusing a maintenance worker of beating him and taking his closet door. Review of hallway camera footage and staffing records showed no staff entry into the room during the night and no male CNAs on duty, contradicting the resident’s accounts. Based on the location of the blood and the absence of staff entry, facility staff concluded that the injuries most likely resulted from an unwitnessed fall that occurred while the resident was unsupervised for an extended period, demonstrating that the facility did not ensure adequate supervision and monitoring to prevent accidents for this high‑risk resident.

The resident’s prior incident history further underscored his need for closer supervision. Earlier incident reports documented a fall in the hallway after he threw his cane and lost his balance, and another unwitnessed event where staff heard a loud bang and found him seated on the floor near his bathroom door, with the resident unable to explain how it happened. Observations during the survey showed that he typically stayed in his room with the door shut, ate meals there, and often refused to sit in a recliner for meals, preferring the edge of the bed. Staff described him as using his call light or yelling from his doorway when he wanted something, and as being noncompliant with attempts to make him an assist‑of‑one for mobility or to use a gait belt. Despite these known behaviors and risks, staff on the night of the incident did not perform in‑person checks or “lay eyes” on him for many hours, which directly led to his injuries from an unwitnessed event that went unrecognized until the morning.

The facility’s own investigation and staff interviews acknowledged that the lack of rounding and failure to visually check the resident during the night were unacceptable and contrary to expectations that residents be checked at least every two hours or hourly. Staff reported that they had been relying on the resident’s call light use and his tendency to yell for assistance, and that the agency aide did not enter the room because the resident disliked having his door opened. The combination of the resident’s closed door, his behavioral and cognitive issues, his fall history, and staff’s failure to conduct required rounds and direct observation resulted in the resident sustaining injuries from an unwitnessed fall or accident that occurred without timely detection or intervention, constituting the cited deficiency in accident prevention and adequate supervision.