Failure to Prevent Resident Neglect Resulting in Actual Harm
Penalty
Summary
The facility failed to ensure that two residents were free from neglect, resulting in actual harm. For one resident with diagnoses including anemia, heart failure, and hypertension, the care plan required transfers with the assistance of two staff members due to high fall risk and dependency. However, the resident was transferred with only one staff member, contrary to the care plan. During this transfer, the resident sustained a skin tear on the lower left leg, which was likely caused by contact with the bed frame. The incident was discovered when the resident was being assisted back to bed after sitting at the nurse's station, and the skin tear was noted and treated at that time. Another resident, diagnosed with arthritis, Parkinson's disease, and depression, also required two-person assistance for transfers and was considered a high fall risk. The care plan specified the use of a call light and prompt staff response for assistance, as well as the provision of a bedpan or bedside commode as needed. Despite these requirements, the resident was left unattended in the bathroom after being transferred to the toilet. The resident attempted to self-transfer, resulting in a fall that caused a dislocation of the right elbow, a fracture of the right distal radius, and a fracture of the right coronoid process of the ulna. The injuries were confirmed by mobile x-ray and hospital evaluation. In both cases, the facility did not follow established care plans and physician orders regarding the level of assistance required for transfers. The failure to provide the necessary staff support directly led to physical harm for both residents. The Director of Nursing confirmed that the required protocols were not followed, resulting in neglect as defined by the facility's own policies and state regulations.