Failure to Prevent Accidents and Ensure Safe Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for multiple residents, resulting in both actual harm and the potential for more than minimal harm. One resident with moderate cognitive impairment and total dependence on staff for all activities of daily living was left unattended in bed with the bed in a high position. This resident fell from the bed, sustaining a nasal fracture and facial lacerations that required sutures. Staff interviews confirmed that the resident was not capable of rolling over or transferring independently, and that the expectation was for the bed to be lowered when staff left the room. However, the bed was left at waist height, and the resident was left alone, directly leading to the fall and injuries. Several other residents who required Hoyer lift transfers with the assistance of two staff members were transferred with only one staff present. One cognitively intact resident sustained a skin tear to his toe during such a transfer. Interviews with staff revealed that, due to staffing shortages or time pressures, staff sometimes performed Hoyer transfers alone, contrary to facility policy and care plan requirements. Residents confirmed that transfers were sometimes performed by a single staff member, and staff acknowledged the deviation from policy. Another resident with severe cognitive impairment and total dependence on staff for mobility and transfers had care plan interventions that were not consistently followed. The care plan required the resident to be laid down after meals to prevent falls from sleeping in a wheelchair, but staff did not consistently document or communicate refusals to comply with this intervention. Observations showed the resident asleep in a wheelchair on multiple occasions, and staff interviews indicated a lack of consistent documentation and communication regarding the resident's refusals and the effectiveness of the intervention.