Failure to Prevent Accidents Due to Inadequate Supervision and Non-Implementation of Safety Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of assistive devices and interventions to prevent accidents for three residents with dementia and significant care needs. One resident, who had a care plan and physician's order requiring the use of a hoyer lift for all transfers due to repeated falls and severe cognitive impairment, was transferred by two CNAs without the mechanical lift. The staff used a two-person manual assist instead of the required device, resulting in the resident sustaining a closed fracture of the left ankle. Staff interviews confirmed that the care plan and physician's orders were not followed, and the staff had not read the relevant documentation. Another resident, with severe cognitive impairment and a history of falls, was care planned to have a fall mat placed next to the bed at all times when in bed. On the day of the incident, a CNA failed to place the fall mat after being distracted by another resident's call for help. The resident subsequently fell out of bed, resulting in multiple injuries including a clavicle fracture, nasal bone fracture, a large skin tear, and abrasions. Staff interviews confirmed the fall mat was not in place at the time of the fall, despite the CNA's awareness of the intervention requirement. A third resident, with moderate cognitive impairment and a recent increase in wandering behavior, was placed on a wander guard alarm and required supervision with smoking. Another resident provided this individual with a cigarette and deactivated the door alarm, allowing the resident to exit the facility unsupervised. While outside, the resident fell and sustained multiple facial fractures, a closed head injury, abrasions, and a rib fracture. The facility's investigation revealed that the door alarm code had been compromised, allowing the resident to leave without staff knowledge or alarm activation.