Failure to Investigate and Address Accident Hazard After Resident Injury
Penalty
Summary
A deficiency occurred when a resident with fragile skin and multiple comorbidities, including lumbar vertebra compression, sick sinus syndrome, postural dizziness, cirrhosis, and kidney failure, sustained a skin tear on their right forearm after hitting it on the armrest of their wheelchair. The incident happened while the resident was in the bathroom, and the injury was attributed to a missing plastic cap on the right armrest, which exposed a sharp metal edge. The missing cap was not visible to the resident while seated but was observable to someone inspecting the wheelchair from the front. Despite the resident reporting the injury and the presence of a visible dressing, no one inspected the wheelchair for hazards following the incident. Multiple observations over several days revealed that the resident continued to use the same wheelchair with the exposed sharp edge, and staff, including the assigned LPN and therapy staff, did not identify or address the missing cap. The LPN, who was present at the time of the incident and on subsequent days, reported checking the wheelchair but did not notice the hazard until it was pointed out by the surveyor. The resident's care plan noted the risk of skin impairment and included general interventions, but there were no updates or specific interventions added after the incident. The facility did not initiate a thorough investigation or root cause analysis immediately following the event, and no incident or accident report was completed until the surveyor brought the issue to the attention of facility leadership. Interviews with staff, including the DON and therapy staff, confirmed that a comprehensive inspection of the wheelchair was not performed in relation to the resident's injury. The facility's policy required prompt investigation and documentation of accidents, including a detailed account of the circumstances and contributing factors, but this process was not followed. The deficiency was identified due to the lack of timely and thorough investigation, failure to identify and remove the accident hazard, and inadequate follow-up to prevent further harm.
Plan Of Correction
1.) Resident #61 is no longer in the facility. All residents have the potential to be affected. 2.) A one-time review of residents in-house was completed to ensure that a root cause analysis was completed for any accident/incident that resulted in an injury. A one-time audit of all wheelchairs was completed to ensure no safety issues were identified. If any were found, they were corrected by IDT. 3.) Licensed nursing staff were re-educated on assessing potential cause of injury due to an accident/incident. System change: Nurse Managers will complete documentation on root cause analysis resulting in injury from accident/incident. 4.) Don/Designee will review 5 E-interact change of condition assessments weekly x 12 weeks to ensure that all injuries from an accident/incident are reviewed for root cause analysis. Any non-adherence will result in 1:1 education. All audits will be taken to QA for review. 5.) The Executive Director is responsible for maintaining compliance with the regulation.