Failure to Provide Adequate Supervision During Toileting for High-Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area was free from accident hazards and to provide adequate supervision to prevent accidents for a resident with a history of falls and severe cognitive impairment. The resident was admitted after a stroke and had severe cognitive impairment, requiring staff assistance for bed mobility, transfers, and toileting. A comprehensive assessment and care plan identified the resident as being at risk for falls due to intermittent confusion and medications that could affect balance and cause dizziness. Fall prevention interventions included sensor alarms and hourly rounding, but there were no directives or interventions in the care plan or bedside care plan requiring staff to stay with or stand by the resident while toileting. In the period leading up to the incident, the resident had five documented falls, several of which occurred when the resident was attempting to get to or use the bathroom. Progress notes showed falls outside the bathroom door, next to the bed, and on the floor mat, with the resident repeatedly stating they needed to use the bathroom. Staff interviews indicated that some staff recognized the resident as impulsive, confused, and unsafe to stand alone, and some reported that they would stay by the bathroom door with it cracked while the resident toileted. The resident’s representative also stated that the resident was confused and impulsive, needed someone to stay by the bathroom, and that staff knew this. On the date of the incident, a nursing assistant responded to the resident calling out to use the bathroom and found the resident standing by the bed beginning to lower their pants. The assistant helped the resident to sit on the toilet, where the resident said it would take a minute. The assistant then left the resident alone in the bathroom to respond to another alarm and assist another resident to and from the toilet. When the assistant returned about five minutes later, the resident was found on the bathroom floor, lying on their left side, with a hematoma on the right side of the forehead, an open area with bleeding, and approximately 90 cc of blood on the floor. The resident was transferred to the emergency department, where CT scans showed subdural hematomas on both sides of the brain. The administrator and DON later acknowledged that the resident’s care plan did not include a directive for staff to stand by during toileting.
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