Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for residents at risk for falls and accidents. One resident with diagnoses including adult failure to thrive, diabetes, chronic kidney disease, and low back pain, who required maximum assistance for standing and toileting, was left unable to reach his urinal. Despite having his call light on and waiting for staff assistance, he attempted to retrieve the urinal himself after waiting for half an hour, resulting in a fall that caused a fractured hip and wrist. The resident reported that staff perceived him as independent due to his age and cognitive status, despite his documented need for assistance. Another resident, dependent on staff for toileting and requiring a sit-to-stand mechanical lift for transfers, slipped out of the lift and fell while being transferred from bed to the bathroom. At the time of the incident, the resident was wearing house shoes instead of the required non-slip footwear, which contributed to the fall. Two staff members were present during the transfer, and the resident reported feeling her feet slip and requested the lift be raised, but the fall occurred regardless. A third resident, who required substantial assistance for dressing and transfers and was to be transferred with a gait belt and two staff, sustained a black eye after falling during a transfer. The resident was left sitting on the edge of the bed while the CNA retrieved clothes from the closet, during which time the resident reached for a shirt and fell forward, hitting his head on the lift. The incident resulted in a cut and swelling to the left eyebrow, as well as scrapes to the left knee and ankle. In each case, the facility did not provide the necessary supervision or ensure the environment was free from accident hazards, directly leading to resident injuries.