Failure to Prevent Accidents and Maintain Hazard-Free Environment
Penalty
Summary
The facility failed to ensure adequate supervision and interventions to prevent major injuries for two residents and to maintain a hazard-free environment for another, as evidenced by multiple falls and injuries. One resident with a history of Parkinson’s disease, dementia, and high fall risk experienced repeated falls, some resulting in injuries such as a laceration above the eye, a thumb fracture, and rib fractures. Despite these incidents, care plan interventions were often repeated rather than updated with new strategies, and there was a lack of timely documentation and interdisciplinary team (IDT) review following several falls. Staff interviews revealed inconsistent knowledge of the resident’s care plan and fall history, and the care plan was not always updated after each incident as required by facility policy. Another resident, who was non-verbal, bed-bound, and dependent for all care due to a traumatic brain injury and spastic hemiplegia, developed significant bruising and swelling to the left leg. The injury was initially attributed to spasticity, but subsequent assessments and imaging revealed a displaced femur fracture. Staff interviews indicated a lack of awareness regarding how the injury occurred, with some staff recalling rumors of a fall or transfer incident but no direct observation or documentation. The facility’s investigation into the injury was inconclusive, and there was no clear evidence of adequate supervision or environmental safety measures to prevent such an injury in a dependent resident. The facility’s policies required comprehensive accident and incident reporting, timely investigation, and care plan updates following accidents or injuries. However, the report documents lapses in these processes, including delayed or incomplete investigations, repeated rather than revised interventions, and insufficient staff communication regarding resident incidents. These failures contributed to the residents experiencing preventable injuries and an environment that was not consistently free from accident hazards.