Failure to Prevent Accidents Due to Inadequate Supervision and Noncompliance with Care Plans
Penalty
Summary
The facility failed to ensure adequate safety measures and supervision were in place to prevent accidents for two of three residents reviewed. One resident, who had a history of cerebrovascular accident (CVA) with left hemiplegia, unsteady gait, and required substantial assistance with transfers and toileting, was left unattended on a commode despite care plan interventions specifying two-person assistance and not to be left alone. This resident experienced a fall in the bathroom after staff briefly exited the room to retrieve linens, resulting in a head injury, laceration, and subarachnoid hemorrhage that required hospitalization. Documentation and interviews revealed inconsistencies in staff awareness and implementation of updated care plans, particularly regarding the required level of assistance and supervision for this resident. Another resident, with diagnoses including mild cognitive impairment, history of falls, and reduced mobility, was being transferred using a mechanical lift by only one staff member, contrary to facility policy and manufacturer guidelines requiring two staff for such transfers. During the transfer, the mechanical lift struck the bed frame, causing the resident to fall out of the sling and onto the floor. Staff statements and interviews confirmed that only one CNA was present during the transfer, and the care plan for this resident required a mechanical lift with two-person assistance for all transfers. The facility's policies on safe handling, transfers, and fall prevention were not consistently followed, as evidenced by the incidents involving both residents. Staff interviews indicated a lack of awareness or adherence to updated care plans and required procedures, contributing to the accidents. These deficiencies resulted in significant harm to one resident and placed both residents at risk for injury.