Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, limited mobility, and contractures was not provided care in accordance with her care plan, which required two-person assistance for bed mobility and use of a mechanical lift for transfers. During incontinent care, a nursing assistant attempted to reposition the resident alone, resulting in the resident rolling off the bed and sustaining significant injuries, including a fractured clavicle, a rib fracture, and a large scalp hematoma. The resident was on blood thinning medication due to a history of pulmonary embolism, further complicating her condition. The nursing assistant admitted to being aware of the two-person assist requirement but did not request help, and the posted note indicating this requirement was not noticed by the assistant at the time of the incident. Additionally, the facility failed to conduct timely smoking assessments for another resident with a diagnosis of tobacco use. The resident's care plan identified a risk for injury related to smoking, and facility policy required quarterly smoking assessments. However, there was a lapse of several months between assessments, exceeding the expected quarterly interval. Despite this, the resident was observed to smoke independently and safely during the survey, with no evidence of burns or injury at the time of observation. Both deficiencies were identified through observation, record review, and staff interviews. The first involved a failure to follow established care protocols for a resident with significant physical and cognitive impairments, resulting in a serious fall and injury. The second involved a failure to adhere to the facility's policy for regular smoking assessments, which are intended to minimize the risk of smoking-related injuries.