Failure to Prevent Resident Self-Injury Due to Inadequate Supervision and Communication
Penalty
Summary
A deficiency occurred when a resident with a known history of banging her head on the wall was not adequately protected from self-injury. The resident, who had diagnoses including paranoid schizophrenia, severe cognitive impairment, and was non-compliant with wearing a protective helmet, required 1:1 supervision as ordered by her physician and outlined in her care plan. The care plan also included interventions such as wall padding and close monitoring to minimize injury. Despite these measures, the assigned CNA was not informed about the resident's specific behavior of head banging and believed the supervision was primarily for fall and wandering risks. On the day of the incident, the CNA was seated beside the resident when the resident quickly got up, walked toward the wall, and began banging her head. The CNA was unable to intervene in time to prevent the injury, resulting in the resident sustaining a laceration on her forehead that required six sutures. The CNA later stated that if she had been aware of the resident's head-banging behavior, she would have been more vigilant and positioned herself closer to the resident to prevent such incidents. Interviews with facility staff and review of records confirmed that the CNA was not properly briefed on the resident's risk behaviors, and the facility's policy on resident safety, which requires identification and mitigation of hazards, was not followed. The lack of communication and failure to implement the care plan interventions directly led to the resident's injury.