Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents who required assistance with mobility and activities of daily living. In the first incident, a non-verbal, cognitively impaired resident who was totally dependent on staff for mobility and required two-person assistance with bed mobility was being repositioned by two CNAs. One CNA left the room to retrieve additional supplies, leaving the other CNA alone with the resident, who was still positioned on her side. The resident's weight shifted, causing her to fall from the bed and sustain a significant head injury, resulting in a traumatic brain injury and hospitalization. Both CNAs and facility leadership confirmed that the resident was known to require two-person assistance and that the policy was not followed when one CNA left the room during care. In the second incident, another resident with moderate cognitive impairment, Parkinson's disease, muscle weakness, and a history of repeated falls was found on the floor after an unwitnessed fall. The resident complained of severe pain and inability to move her right leg, and requested an x-ray. Staff assisted the resident to bed and then used a mechanical lift to transfer her to a wheelchair, despite her complaints of pain and immobility. There was a delay of over six hours before emergency transport was called to take the resident to the hospital, where she was diagnosed with a displaced subcapital right femoral neck fracture. Interviews revealed that staff did not immediately call 911 and moved the resident despite her symptoms, contrary to expected protocol. The facility's policies required two-person assistance for certain residents and outlined procedures for responding to falls and pain management. However, in both cases, staff failed to follow these protocols, resulting in significant harm to the residents. The incidents were confirmed through medical record review, staff and family interviews, and facility investigations, and led to the identification of Immediate Jeopardy due to the serious injuries sustained by the residents.
Removal Plan
- Educated CNA A and CNA B on 2-person assist with bed mobility and positioning and repositioning the resident while providing care.
- Reviewed all falls, policies, Kardex's and care plans to align with each resident's current bed mobility needs.
- Began in-servicing on Fall Management Program, Safety and Supervision of the Resident, and Positioning and Repositioning of the resident for all licensed Nurses, CNAs, and Respiratory Therapist.
- Implemented Fall audits, Care plan audits, Kardex audits, Policy audits, and on-going education with Licensed Nurses, CNAs, and Respiratory Therapist on 2-person assist with bed mobility to call for help and not leave the room if they need any supplies.
- Conducted skills competency with positioning and repositioning residents with return demonstration to prevent recurrence.
- Monitoring all falls daily.
- Ensuring all care plans and Kardex's are up to date.
- Ongoing competencies and education to ensure training is effective.
- Measuring effectiveness of the in-services by monitoring the falls on a daily basis and observing return demonstrations through competency.
- Conducted a facility wide fall audit with no major injuries.
- Conducted a facility wide care plan audit to ensure any resident that is a 2-person assist reflects accurately and was found to be up to date.
- Conducted a facility wide Kardex audit to ensure all residents had an up-to-date Kardex and aligning with current care plan with 2-person assist with bed mobility.
- Reviewed policies on Fall Prevention Program, Safety and Supervision of Residents, and Repositioning by the Administrator and Director of Nursing with no revisions needed.
- In-serviced all licensed Nurses, CNAs, Respiratory Therapist, any nursing agency personnel and any Nurses, CNAs, Respiratory Therapist on Leave of Absence (LOA) on Fall Prevention, Safety and Supervision of Residents, and Repositioning.
- Continuing ongoing Quality Assurance Plan to monitor facility performance and compliance with the Fall Prevention Program, Safety and Supervision of Residents, and Repositioning by continuing to monitor falls daily and implementing planned interventions and approaches appropriately.