Failure to Prevent Accidents and Ensure Safe Environment for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents with significant cognitive and physical impairments. One resident with dementia, a history of cervical vertebra fracture, and a high fall risk was repeatedly observed in a reclined Broda chair with her call light out of reach, despite her care plan specifying that the call light should always be within reach. Staff interviews confirmed that the resident was unable to reposition herself or access the call light independently, and that all residents on the unit were considered high fall risks. The facility's own policy required interventions to minimize fall risk, but these were not consistently implemented as observed during the survey. Another resident with severe cognitive impairment, bilateral lower extremity impairment, and total dependence on staff for transfers and mobility suffered two separate head lacerations during staff-assisted transfers. In both incidents, documentation was incomplete or lacking, with no root-cause analysis or clear description of how the injuries occurred. Staff interviews revealed improper use of mechanical lifts, lack of supervision, and failure to immediately report and document injuries. Witness statements indicated that staff left the resident unattended during transfers, and that the resident became agitated, leading to injury. The facility's fall management policy required assessment and care planning for fall risks, but these procedures were not adequately followed. A third resident with dementia, unsteadiness, and a history of falls was found on the floor with a head laceration after an unwitnessed fall. The resident's bed was found in a high position, and the bed control was accessible to the resident, despite staff stating that residents with dementia should not have access to bed controls due to fall risk. The facility lacked an assessment to determine if the resident was safe to operate the bed device. The care plan required staff to ensure the resident was not put to bed until fatigued and to keep the call light within reach, but these interventions were not consistently implemented. The facility's failure to follow its own policies and care plans placed residents at risk for preventable falls and injuries.