Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, who was cognitively intact and required a sit-to-stand mechanical lift for transfers due to musculoskeletal impairments and a history of stroke, was manually transferred by a CNA without the required lift device. During this transfer, the resident experienced a popping sound in her leg, followed by pain, swelling, bruising, and redness. Despite these symptoms, the facility did not assess her pain or change in condition, nor did they provide timely treatment or X-rays. The injury was only properly addressed after the resident reported increased pain to her community physician, who then ordered X-rays and facilitated a hospital transfer, where fractures of the right distal tibia and fibula were diagnosed. The facility also failed to update the resident's care plan to reflect the new fracture as a risk factor and did not investigate the injury when it was first reported by the resident and observed by staff. Another resident with severe cognitive impairment, a history of repeated falls, and an above-the-knee amputation was not provided with person-centered fall interventions tailored to her cognitive deficits. Despite multiple unwitnessed falls, the interventions implemented primarily focused on visual cues such as signs and colored tape to prompt the resident to use her call light and lock her wheelchair brakes. Therapy and nursing documentation indicated that the resident had significant deficits in memory, executive functioning, and safety awareness, which limited her ability to benefit from interventions requiring memory recall and judgment. Staff interviews revealed that additional interventions, such as frequent checks and toileting, were verbally communicated but not documented in the care plan, and there was no evidence of a systematic review of why previous interventions failed after each fall. The facility's interdisciplinary team did not consistently review or update care plans to include effective, individualized interventions based on the residents' needs and cognitive abilities. There was a lack of documentation and follow-up regarding staff observations of injuries and pain, and the process for implementing and communicating fall interventions was not clearly defined or consistently followed. These failures resulted in preventable injuries and inadequate supervision for residents at risk for accidents and falls.