Failure to Prevent Accidents and Ensure Safe Transfers
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for several residents. One resident with Alzheimer's disease, dementia, and Parkinson's disease, who was severely cognitively impaired and at risk for falls, was left unattended in a shower chair for an extended period. Staff interviews confirmed that the resident required two staff for transfers, but due to short staffing, she remained in the chair for a prolonged time, resulting in red indentations on her leg. Staff and the DON acknowledged that residents should not be left alone in shower chairs. Another incident involved a resident with severe cognitive impairment and gait abnormalities who was knocked down by another resident in a wheelchair, resulting in a large hematoma to the back of her head and a headache. The resident was transferred to the ER and later returned. The resident who caused the incident had a history of unsafe wheelchair use, including propelling himself backwards and running into others. Despite previous behavioral issues and staff concerns, the care plan lacked sufficient interventions to ensure wheelchair safety for this resident and others. Additionally, a resident dependent on staff for transfers fell from a mechanical lift due to the use of an inappropriate sling. Staff involved in the transfer noted that the sling was not the usual type, appeared unsafe, and was not designed for bed-to-chair transfers. Despite concerns raised during the transfer, the process continued, resulting in the resident sliding out of the sling and sustaining a hematoma and abrasion to the head. The facility also failed to ensure oxygen tanks were properly secured during transport, as observed on multiple occasions with staff carrying and setting tanks down without holders, contrary to facility policy.