Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. In one case, a resident with severe cognitive impairment, limited mobility, and a history of lumbar compression fractures was transferred using a mechanical standing lift by a CNA, despite the resident's care plan specifying the use of a full body lift (Hoyer lift) and requiring a two-person assist. The CNA operated the standing lift alone, and during the transfer, the resident's foot slipped, causing her to fall to her knees and sustain additional compression fractures to her lumbar vertebrae. Multiple staff interviews confirmed that the standing lift was used at the request of the resident's family member, contrary to the care plan and physical therapy recommendations, and that some staff had previously used the standing lift for this resident due to family requests. In another incident, a resident with severe cognitive impairment and a history of dementia, acute kidney failure, and syncope was found unsupervised in the facility's parking lot in her wheelchair. The resident was not considered high risk for elopement according to her most recent assessment and had not previously exhibited exit-seeking behavior. Security camera footage showed the resident leaving the facility by following a family member out the door, remaining outside for several minutes before being returned to the facility by another family member. Staff interviews indicated that the resident was confused and forgetful, and that the doors were typically monitored by security, but it was unclear how the resident was able to exit the building without being noticed. Both incidents demonstrate failures in following established care plans and supervision protocols. In the first case, staff did not adhere to the prescribed transfer method and number of assisting personnel, and in the second, the facility did not ensure adequate monitoring to prevent a resident with cognitive impairment from leaving the premises unsupervised. These failures resulted in actual harm in the form of injury for one resident and placed both residents at risk for further harm.