Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment and equipment were free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, with multiple diagnoses including chronic kidney disease, diabetes, morbid obesity, and a history of falls, was non-ambulatory and required total assistance with transfers using a Hoyer lift. On the day of the incident, after being transferred to a geri-chair for dialysis, the staff left the resident unattended. The geri-chair malfunctioned, causing the resident to fall and become wedged between the chair and the wall, resulting in a closed head injury, neck strain, and right shoulder contusion. The resident was subsequently transferred to the emergency room for evaluation. The incident was not investigated or reported by the Director of Nursing, despite facility policy requiring a safe environment to reduce fall risk. Another resident, diagnosed with dementia and a history of falls, was identified as an elopement risk and had severe cognitive impairment. The care plan included interventions such as disguising exits and providing diversions, but the resident was able to leave the supervised TV room and access an emergency egress stairwell. Staff last observed the resident in the TV room and by the nurse’s station, but she was later found on the floor at the top of the stairs, with her wheelchair at the base of the stairs. The emergency exit door was propped open and the alarm was sounding when emergency responders arrived. The resident complained of hip pain and was transferred to the emergency room for evaluation. Staff interviews revealed that wandering residents were supposed to be supervised in the TV room, but the resident was able to leave unsupervised. Both incidents demonstrate a failure to maintain a safe environment and provide adequate supervision for residents at high risk for falls and elopement. The facility did not follow its own policies for fall prevention and management, nor did it ensure that residents with known wandering behaviors were properly monitored and redirected, resulting in serious injuries and emergency transfers.