Failure to Adequately Supervise High Fall-Risk Resident During Ambulation
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a newly admitted resident who was identified as high risk for falls and injuries. The resident was admitted with dementia, major depressive disorder, and schizophrenia, and was care planned on admission as being at high risk for injury, accidents, and falls, with interventions including maintaining a safe, hazard-free environment, keeping the bed in low position with bilateral floor mats, and monitoring the resident’s location as often as possible. The resident’s MDS showed moderately impaired cognitive skills for daily decision-making and a need for partial/moderate assistance with ADLs, as well as supervision or touching assistance for transfers and walking. A Fall Risk Evaluation documented intermittent confusion, balance and gait problems, decreased muscular coordination, use of assistive devices, and three or more predisposing diseases, with a total score of 20, indicating high fall risk. Despite these identified risks and care plan interventions, the resident was observed by a family member walking alone in the hallway without staff supervision, and no staff were present in the immediate area monitoring the resident. The family member reported having to search for staff and, upon informing a CNA that the resident was walking alone, the CNA did not immediately intervene. CNA2 later stated that on the date in question, she was covering another CNA’s break in the dining area and was unable to visually observe all residents, and did not see the resident ambulating in the hallway. RN1 explained that resident monitoring was done through frequent checks and staff awareness rather than continuous observation, and noted that the resident was new and staff might not have been fully familiar with the resident’s needs. The DON stated that staff were expected to follow care plans and provide monitoring, and confirmed that the resident was alert but confused, ambulatory, and required assistance with walking. The facility’s fall prevention policy required close monitoring and observation of at-risk residents for ambulation and transfer attempts with supervision and assistance as needed, which was not implemented for this resident at the time of the incident.
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