Inadequate Supervision Leads to Resident Injury
Penalty
Summary
Towne Manor West was found to be non-compliant with federal and state regulations due to a failure in providing adequate supervision during incontinence care for a resident, resulting in actual harm. The facility's policy required assistance from more than one staff member for residents needing two-plus person physical assistance for bed mobility. However, during an incident, a single staff member attempted to provide care, leading to the resident falling out of bed and sustaining fractures to the left arm and hip. The resident, who had severe cognitive impairment and required significant assistance for bed mobility, was not adequately supervised according to their care plan. The resident involved had a history of chronic obstructive pulmonary disease, lack of coordination, abnormalities of gait and mobility, and dementia. The incident occurred when a nurse aide, while providing care, asked the resident to roll over, resulting in the resident falling from the bed. The facility's documentation and staff interviews confirmed that the resident required two-plus person assistance for bed mobility, which was not provided at the time of the incident. This lack of adherence to the care plan and facility policy led to the resident's injuries, highlighting a significant lapse in supervision and care.
Plan Of Correction
All residents have the potential to be affected by this deficient practice. 1) The Director of Nursing (DON) immediately updated the care plan of the resident with 2 assists for turning and repositioning. 2) The Facility educator and/or designee will in-service all the nurses, Minimum Data Set (MDS) Coordinator, and Certified Nursing Assistants (CNA) on Federal Guidelines F 689 related incident and accidents. 3) The Facility Educator and/or designee will in-service all the nurses and Certified Nursing Assistants (CNA) on accuracy of documentation in the Point of Care Service (POC) task. 4) The DON and/or designee will in-service the MDS Coordinator on accuracy of MDS assessment and documentation of CNA in the POC. 5) The DON and/or designee will audit 5 residents' ADL care plan to ensure that resident's bed mobility/turning and repositioning are documented according to the Point of Care Task/Kardex weekly x 4 weeks and monthly x 3 months. The DON will submit the audit reports to the Quality Assurance Committee.