Failure to Provide Adequate Supervision for High Fall-Risk Resident on 1:1
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident at high risk for falls, resulting in a fall with major injury. The resident was admitted from the hospital with multiple fractures, including a right elbow fracture, was non–weight bearing to the right upper extremity, and had severe dementia with poor memory and severe aphasia. Assessments and the Falls CAA documented that the resident had a history of falls with fracture prior to admission, altered mental status, impaired mobility, and was considered at high risk for falls. Progress notes indicated the resident was described as "busy" but not behavioral, and identified risks including falls, pain, injury, and decline. On the day of the fall, documentation and staff interviews showed that the resident had been placed on one-to-one (1:1) supervision by nursing staff due to restlessness and safety concerns. The resident was being supervised in an open dining/commons area, self-propelling in a wheelchair while staff attempted to keep her under watch and provide snacks. The primary NA assigned to the resident reported that the resident had been under 1:1 supervision, moving around the unit in her wheelchair under observation. However, when another NA requested assistance with a two-person transfer for another resident, the supervising NA moved the resident near the other room, briefly left her unattended to assist with care behind a closed door, and then later left her again out of sight to dispose of trash and wash hands down the hall. During these periods, the resident was not under continuous observation despite staff acknowledging she was considered 1:1. During the time the resident was left unsupervised, she self-propelled her wheelchair into the dining room and experienced an unwitnessed fall. She was found on the floor in the middle of the room with her wheelchair behind her, having sustained head lacerations and an injury to her left elbow. The Fall Scene Investigation and follow-up documentation identified that the resident had hit her head and that the fall resulted in a displaced left olecranon fracture, later confirmed in the ED and requiring surgical intervention. The root cause section of the fall investigation noted that the resident was not on 1:1 at the time of the fall and that she had self-propelled and attempted to get up, leading to the fall. Staff interviews confirmed that they understood 1:1 to mean constant supervision and that leaving the resident alone, out of sight, occurred despite this understanding. The care plan, however, did not contain any intervention for 1:1 supervision, and facility leadership acknowledged there was no specific policy defining 1:1 expectations and differing interpretations existed regarding whether the resident required direct constant supervision versus frequent checks.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.