Failure to Prevent Accidents and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure the safety and adequate supervision of two residents, resulting in deficiencies related to accident hazards and fall prevention. One resident, who had intact cognition but significant physical limitations and a history of falls, required assistance from two staff members and the use of a standing mechanical lift for all transfers, including toileting. Despite these requirements being clearly documented in the care plan and CNA Kardex, a staff member left the resident unattended in the bathroom after assisting with toileting and peri-care, stepping out to seek help for the transfer. During this absence, the resident attempted to self-transfer from the toilet to the wheelchair, resulting in her knees giving out and the staff member having to lower her to the floor. The resident sustained abrasions to her back during this incident. Interviews and documentation revealed that the staff member was aware of the resident's need for two-person assistance but proceeded to stand the resident up alone for peri-care and left her unsupervised in the bathroom. There was also a significant delay in the nurse's response to the incident, as the nurse prioritized completing a medication pass before assessing the resident. The nurse did not immediately assess the resident's injuries, and the required assessment of the resident's back was not completed until the following day. Staff interviews confirmed that the care plan was not followed, and the nurse did not respond promptly to the fall, leaving the resident on the floor for an extended period before being assisted back to her wheelchair. In a separate incident, another resident with moderate cognitive impairment and a history of falls was found on the floor after attempting to transfer from a wheelchair to bed and experiencing dizziness. The care plan for this resident did not include any new interventions following the fall, despite facility policy requiring investigation and implementation of preventive measures after such events. The Director of Nursing acknowledged the lack of intervention and documentation for this incident, which was inconsistent with facility policy and expectations for fall prevention and resident safety.