Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe and supervised environment to prevent accidents and hazards for three residents. In one instance, a resident with multiple rib fractures fell and was moved by staff before being assessed for injuries, contrary to facility policy and staff training. The licensed nurse involved acknowledged that the resident should not have been moved prior to assessment, and the Director of Nursing confirmed that the correct procedure was to assess for injuries before moving any resident after a fall. Additionally, the resident experienced blurred vision and headaches following the fall, but the physician was not notified of these symptoms until five days later, resulting in a delay in treatment. The physician stated that if he had been informed earlier, he would have ordered the resident to be transferred to the emergency department for evaluation. For another resident, clinical documentation was incomplete following a fall, specifically the post-fall assessment for the night shift was not completed. The Director of Nursing confirmed this omission and explained that post-fall assessments are necessary to ensure there are no hidden injuries and to implement appropriate interventions. In a third case, a resident with hemiplegia and hemiparesis had incomplete neurocheck documentation after a fall, with most vital signs recorded prior to the fall rather than after. Additionally, this resident was observed wearing regular socks instead of the required nonskid footwear, despite care plan interventions specifying the use of nonskid socks to prevent falls. Both a CNA and a licensed nurse confirmed that the resident should have been wearing nonskid socks to reduce the risk of further falls. Facility policies reviewed indicated that residents should be assessed for injuries before being moved after a fall, that post-fall monitoring should occur for at least 72 hours, and that changes in condition should be promptly communicated to the physician. The failures identified in these cases resulted in delayed treatment, incomplete documentation, and failure to follow care plan interventions, all of which had the potential to negatively affect the health and well-being of the residents involved.