Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for four residents, resulting in multiple falls and injuries. One resident with diagnoses including brain neoplasm, dementia, and lung neoplasm was identified as a high fall risk and had a care plan with multiple interventions such as non-slip footwear, signage, and a bolstered mattress. Despite these interventions, the resident experienced at least twelve falls, including one that resulted in a skin tear to the right knee. Observations revealed the resident was frequently not wearing non-slip socks or shoes, the call light was found on the floor, and the bolstered mattress was not in place as care planned. Staff interviews confirmed the expected interventions were not consistently implemented, and the resident’s family expressed concerns about inadequate supervision and missing safety equipment. Another resident with severe cognitive impairment and a history of wandering was care planned as an elopement risk and resided on a secured unit. However, observations showed the resident wandering into other residents’ rooms without staff intervention, and another resident reported the need to keep their door closed to prevent this. The care plan interventions, such as providing supervision and diversional activities, were not observed to be consistently followed during the survey. Two additional residents, both high fall risks with cognitive impairments, were observed being transferred by CNAs who did not use gait belts as required by their care plans and facility policy. Although staff stated they use gait belts for transfers, direct observation showed that gait belts were not used on the residents during transfers, despite being carried by the staff. Facility policies and care plans specified the use of gait belts to promote safety, but these were not adhered to during the observed transfers.