Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to provide effective supervision and implement adequate interventions to prevent accidents for two residents with significant cognitive and physical impairments. One resident with right-side hemiplegia, lack of coordination, abnormal posture, and dementia was left unsupervised in the dining room while agitated, resulting in a fall from a wheelchair. Staff interviews revealed that the resident was placed in the dining room during a room cleaning, became agitated, and attempted to open the door, leading to the fall. There was confusion among staff regarding who was responsible for monitoring the dining room at the time, and the facility was unable to identify who was supervising the area when the incident occurred. The resident sustained a clavicle fracture and required hospital treatment. Another resident with dementia, a history of falls, and a healing left humerus fracture experienced two unwitnessed falls from bed. This resident was assessed as high risk for falls and was dependent on staff for repositioning in bed. Despite interventions such as placing the bed in the lowest position and using a floor mat, the resident continued to fall, sustaining injuries including a closed head injury, scalp abrasion, and swelling of the left upper extremity. Staff acknowledged that the interventions in place were ineffective in preventing the resident from falling out of bed, and it was unclear how the falls occurred given the resident's dependence on staff for mobility. The facility's fall prevention and management policies require identification and evaluation of residents at risk for falls, planning of preventive strategies, and ensuring a safe environment. However, in both cases, the facility did not provide adequate supervision or effective interventions, resulting in serious injuries to both residents. The lack of clear staff assignment and monitoring contributed to the deficiencies in resident safety and accident prevention.