Failure to Ensure Accident Hazard Prevention and Safe Transfer Practices
Penalty
Summary
Surveyors identified that the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for three residents with a history of falls and severe cognitive impairment. Specifically, these residents were found to have scoop mattresses on their beds without corresponding physician orders or documentation in their care plans. Observations confirmed the presence of the scoop mattresses, and interviews with nursing staff and administration revealed a lack of awareness regarding the requirement for physician orders for such specialty equipment, despite other residents in the facility having appropriate orders. Additionally, the facility failed to ensure that a certified nursing assistant (CNA) used a gait belt when transferring a resident from bed to wheelchair. The CNA manually transferred the resident without a gait belt, despite knowing it was required for safe transfer, citing the absence of a gait belt in the room as the reason. Interviews with nursing staff, the DON, and the administrator confirmed that the use of a gait belt is an established policy and expectation for all manual transfers to prevent resident injury. Record reviews and staff interviews further substantiated that the facility's policies require physician orders for specialty equipment and the use of gait belts during transfers. The lack of adherence to these policies resulted in residents being exposed to potential accident hazards, as evidenced by the observed practices and documentation gaps.