Failure to Prevent Accident Hazards and Ensure Safe Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that accident hazards were minimized and that adequate supervision and assistance were provided to prevent accidents for two residents identified as being at high risk for falls. One resident, who was cognitively intact and had diagnoses including heart failure, arthritis, and chronic obstructive pulmonary disease, required supervision or assistance for mobility and transfers. Despite being assessed as high risk for falls and having a care plan specifying the need for safe transfer and supervision, this resident was observed being transported by a nursing assistant while seated on a four-wheeled walker, which was used as a transportation device against manufacturer warnings. The nursing assistant admitted to routinely transporting the resident in this manner and was unaware that this practice was unsafe and not permitted. Another resident, who had severe cognitive impairment and required extensive assistance with activities of daily living, had a history of multiple falls in the facility. The resident's care plan included specific interventions such as ensuring the walker was within reach at all times to prevent self-transfers and falls. However, during multiple observations, the resident's walker was found out of reach, positioned several feet away from the resident while seated in a recliner. Staff interviews confirmed that the walker should have been within reach, and the resident was at continued risk for falls due to this oversight. Facility policies required individualized fall risk assessments and implementation of care plan interventions to minimize fall risk, as well as safe handling and transfer procedures. Despite these policies, the facility did not consistently implement or monitor the required interventions for residents at high risk for falls, resulting in unsafe practices and failure to provide adequate supervision and accident prevention.