Failure to Provide Adequate Supervision and Proper Use of Assistive Devices Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and proper use of assistive devices for a resident who was at risk for falls. The resident, who had therapy recommendations for ambulation with a front-wheeled walker, contact guard assist, and a wheelchair to follow, was being assisted by a CNA during ambulation. The CNA reported using a gait belt and gripper socks, with one hand on the gait belt and the other pulling the wheelchair behind. When the resident expressed fatigue and a desire to sit, the CNA attempted to position the wheelchair but lost contact with the resident, resulting in the resident losing balance and falling sideways into a wall. The resident sustained a right femur fracture and required surgical intervention. Documentation and interviews revealed that the CNA was not fully aware of the specific contact guard assist requirement and believed the resident was an assist of one during ambulation. The incident report and progress notes confirmed that the plan of care, which required close supervision and specific assistive techniques, was not fully adhered to at the time of the fall. The lack of consistent application of the recommended supervision and assistive device use directly contributed to the resident's fall and subsequent injury.