Failure to Prevent Accidents Due to Inadequate Supervision and Noncompliance with Care Plans
Penalty
Summary
The facility failed to ensure that residents were protected from accident hazards and received adequate supervision to prevent accidents. In one incident, a CNA transferred a dependent resident with a history of traumatic brain injury, cognitive deficit, and peripheral vascular disease from bed to a chair without using the required mechanical lift and without the assistance of a second staff member, as specified in the resident's care plan. The CNA manually lifted the resident, resulting in the resident sustaining a nondisplaced spiral fracture of the right tibia and multiple left lower rib fractures. Documentation and staff statements confirmed that the mechanical lift was not used, and the transfer was not performed according to the resident's plan of care. Another incident involved a resident with a history of stroke, osteoporosis, severe cognitive impairment, and a high risk for falls. The resident required moderate to maximum assistance for transfers and was identified as a fall risk. While being assisted in the bathroom, the CNA left the resident unattended to retrieve socks, during which time the resident attempted to self-toilet and fell, resulting in a head laceration that required staples. The care plan and CNA care card indicated that the resident should not be left alone due to the high risk of falls, but this protocol was not followed at the time of the incident. Both incidents demonstrate a failure to follow established care plans and safety protocols for residents with significant physical and cognitive impairments. The lack of adherence to transfer and supervision requirements directly led to serious injuries, including fractures and a head laceration, for two residents who were dependent on staff for safe mobility and toileting.