Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent accidents and falls for three residents. One resident with severe cognitive impairment and multiple diagnoses was being prepared for transfer to a shower chair by a CNA who was waiting for a second staff member to assist. The CNA sat the resident on the side of the bed with a walker in place and turned away to respond to another resident's question. During this time, the resident slid off the bed and sustained fractures to both legs. Documentation confirmed the injuries and the sequence of events, and the Director of Nursing acknowledged the deficient practice. Another resident, also with severe dementia and a history of wandering and ingesting non-food items, was assigned 1:1 supervision due to being a fall risk and exhibiting unsafe behaviors. Despite this, the resident was found sucking on a bleach sheet, requiring intervention from poison control. Staff assignment records showed that one CNA was responsible for supervising both this resident and his roommate, who also required close supervision. Staff interviews revealed that it was very difficult to supervise both residents simultaneously, and that lapses in attention allowed the resident to access hazardous items. The roommate, who had dementia and a history of wandering and exit-seeking behaviors, was also at risk for falls and elopement. Despite care plans indicating these risks, the resident was able to exit through an alarmed door and go down a flight of stairs without staff intervention. There was no investigation documented for this incident, and staff confirmed that supervision was not consistently provided as required. The facility did not provide incident reports or investigations for some of these events, and staff interviews confirmed that supervision protocols were not adequately followed.