Failure to Ensure Competent Staffing and Timely Injury Assessment
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to safely provide direct care and nursing services, resulting in preventable injuries and delayed medical treatment for a resident. Certified Nurse's Aide (CNA) Q was involved in two separate incidents where the resident sustained head lacerations requiring sutures. In the first incident, the resident received a scalp laceration during a transfer from a wheelchair to a bed using a sit-to-stand lift, with no clear explanation or root-cause analysis documented. Witness statements were referenced but not provided, and the incident report lacked details on how the injury occurred. In the second incident, CNA Q turned the resident without additional staff assistance during incontinence care, resulting in the resident hitting his head on a wall outlet and sustaining a forehead laceration. The resident was found with a blood-saturated bandage, and there was no documentation of a nursing assessment at the time of injury. The physician was not notified until the next shift, and the facility could not provide evidence that the resident was assessed by a nurse immediately following the injury. Staff interviews confirmed that injuries were not reported or assessed as required by facility policy.