Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident, resulting in the resident rolling off the bed and sustaining injuries. The resident, who was admitted with multiple diagnoses, was documented to require a two-person assist for bed mobility and bathing according to the care plan. However, the Certified Nurse Aide (CNA) instructions were inconsistent, initially indicating a one-person assist, which was later changed to a two-person assist without a documented date. During an incident, the resident was being cared for by a CNA who turned away to get a washcloth, during which the resident rolled off the bed and fell to the floor, sustaining a laceration and abrasions. The incident report concluded that the fall was witnessed and caused by the resident's intent or behavior. The resident was sent to the hospital for a CAT scan and returned in stable condition. Interviews with the CNA involved revealed a lack of communication regarding changes in the resident's care requirements, as the CNA was unaware of the need for a two-person assist. The physical therapist confirmed that the resident required extensive two-person assistance. The facility's failure to ensure proper communication and adherence to the care plan led to the resident's fall and subsequent injuries.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 689 P(NAME) Description: I. Immediate Corrective Action: Resident #165 is no longer at the facility. II. Identification of others: All residents will be reviewed to ensure the following: (1) Supervision status is accurately reflected in the CCP and CNAAR. (2) If care plan or CNAAR is not updated appropriately, it will be immediately rectified. All resident charts were reviewed to ensure the appropriate supervision status. None others were identified. III. Systemic Changes: a. The Director of Nursing and Administrator reviewed the policy and procedure regarding Supervision. It was found to be in compliance. b. The Director of Nursing and Administrator reviewed the policy and procedure for accidents and incidents and found to be in compliance. c. All Nursing staff will be inserviced by ADNS, DON on the importance of checking the CNAAR for the final determinant of a resident's supervision status. All C.N.A.s will receive education on checking the CNAAR for appropriate supervision status. IV. QA monitoring: a. An audit tool was created to monitor all residents' supervision status to ensure its accuracy. b. Audits will be conducted weekly for 4 weeks for all residents, then monthly for 11 months. c. All negative findings will be reported to the Director of Nursing and the administrator and will be corrected immediately. d. All results of the audits will be brought to the QAPI committee quarterly for a year. V. Person Responsible: Director of Nursing.