Inadequate Supervision and Hazardous Environment Lead to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for Resident #24, who is cognitively impaired and exhibits agitated behaviors. The resident sustained a laceration and fractures to the right foot after being found with their foot on a radiator, which was reported to have sharp edges. Despite the incident, the facility did not report the accident to the New York State Department of Health as required. Resident #24 has a history of severe cognitive impairment, anxiety disorder, bipolar disorder, and schizophrenia. The resident is frequently incontinent and requires supervision for daily activities. On the day of the incident, the resident was found with a laceration on the right foot, which was bleeding. The injury was severe enough to require hospital evaluation and treatment, including orthopedic surgery and laceration repair. Interviews with staff revealed inconsistencies in the facility's response to the incident. The Registered Nurse on duty observed sharp edges on the radiator, but the Maintenance Director and Worker later reported no sharp edges. The Director of Nursing did not report the incident, believing it was unnecessary since the cause of the injury was known. This lack of communication and failure to report the incident highlights deficiencies in the facility's accident prevention and reporting protocols.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 F689 Corrective action for Resident Identified: Nursing conducted an immediate assessment of resident #24 to address their safety and supervision needs. Care plan for resident #24 was updated to ensure safety and proper monitoring. A review of the resident's environment was conducted to ensure any necessary devices are in proper working order and available for use. Individualized interventions such as increased supervision i.e. spending more time supervised in the activities/dayroom to mitigate risks were implemented. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The facility conducted an environmental assessment for all residents to identify potential hazards and supervision needs. Results of this assessment were reviewed by the Administrator, DNS and ADNS. No other residents were found to be affected by this practice. An audit tool was developed to monitor compliance. Element 3 Systemic Changes: The facility policy and procedure titled Accident and Incident Report was reviewed and no revisions were required. Staff Education and training: The Risk Manager/ADNS will provide training to appropriate staff (CNA, LPN, RN, maintenance, housekeeping, and social services and rehab) on accident prevention, hazard identification, and the proper use of assistive devices. The training will emphasize the importance of timely reporting and addressing potential hazards. Routine preventative room rounds conducted by all nursing staff are being implemented to ensure that residents whose preference is to remain in their room receive adequate supervision to prevent any further occurrences. Element 4 Monitoring of Corrective Action: On a weekly basis for one quarter, the DNS, ADNS, and Medical Director will audit incident reports weekly to identify trends and ensure follow-up action is completed. Monthly audits of care plans, supervision, and environmental safety measures will also be monitored. The Maintenance Director will conduct weekly routine environmental audits for 3 months to identify and eliminate physical hazards. On a monthly basis for 3 months, the results of the audits will be reported to the administrator; any negative findings will be addressed immediately. The results of the audit will be presented to the QAPI Committee for 3 quarters for monitoring and compliance. The QAPI committee will determine if further action is required. Element 5 Completion Date: (MONTH) 12, 2025 Responsible Persons: Director of Nursing, ADNS and Maintenance Director