Failure to Prevent Accidents and Complete Required Incident Documentation
Penalty
Summary
The facility failed to ensure residents were free from accident hazards and did not provide adequate supervision to prevent accidents, as evidenced by two separate incidents involving two residents. In the first case, a resident was found on the floor in their room after their bed had flipped onto its side, though not onto the resident. Despite facility policy requiring completion of an incident report and documentation of all assessments and actions following a fall, no incident report or investigation was completed for this event. The Director of Nursing confirmed that the required documentation was not done, and no additional documentation was provided to the surveyor. In the second case, another resident reported falling to the floor when a Hoyer lift tilted during a transfer from wheelchair to bed. The resident subsequently experienced back pain and was transferred to the emergency department. The incident was documented in the medical record, and interviews revealed that the transfer was being performed in the hallway due to limited space in the resident's room. The Hoyer lift involved was removed from service and inspected, but no mechanical issues were found. The facility had been in the process of replacing older Hoyer lifts, and the one involved in the incident was replaced following the event.