Failure to Prevent Accident Hazards and Ensure Proper Resident Assessment
Penalty
Summary
The facility failed to recognize and address potential hazards related to residents attending community appointments unsupervised and did not ensure a resident was properly assessed for the use of a sit-to-stand lift for transfers. In one instance, a resident with diagnoses including dementia, COPD, malnutrition, anxiety, psychosis, and alcohol dependence, who resided on a secured unit due to impaired cognitive function and risk for elopement, was allowed to leave the facility for a supposed health clinic appointment without verification. The nurse on duty did not check the resident's appointment documentation or confirm with the clinic before permitting the resident to leave in an unmarked car. Later, it was discovered that the clinic had not scheduled an appointment and had not sent transportation. The resident did not return to the facility and later communicated that he would not be coming back, resulting in the facility contacting the family, adult protective services, and the police. The facility's policy required investigation and reporting of all missing residents, but the incident was not initially reported as an elopement. In another case, a resident with a history of cognitive communication deficit, heart failure, COPD, atrial fibrillation, depression, anxiety, and dementia was assessed as requiring a two-person transfer with a mechanical lift. After a recent hospital stay for stroke-like symptoms, the resident exhibited increased weakness and left-sided deficits. During observation, two CNAs assisted the resident with a transfer using a sit-to-stand lift, but the resident was not able to properly grip the lift with his left hand due to weakness and was observed leaning to the left side in his wheelchair. The therapy director confirmed that the resident had not been assessed for the use of a sit-to-stand lift and should have been transferred with a gait belt and two-person assist. The facility's policy required ongoing assessment of residents' transfer needs by nursing and rehabilitation staff, but this was not followed in this case. Both deficiencies demonstrate failures in supervision and assessment, specifically in verifying the safety of residents leaving the facility for appointments and in ensuring proper evaluation for transfer equipment. The lack of adherence to established policies and procedures contributed to unsafe situations for the residents involved.