Failure to Provide Adequate Supervision and Assistance Devices to Prevent Resident Accident
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and hemiparesis following a stroke, who used an electric wheelchair and was care-planned for a seat belt-gait belt, was not provided with adequate supervision and assistance devices to prevent accidents. The care plan specified the use of a seat belt, but staff were unable to secure it around the resident because it was too small, and this issue was known but not reported or addressed. The resident subsequently slid out of the wheelchair, sustained a leg laceration, and had to call emergency services for assistance after yelling for help without response. Staff interviews revealed uncertainty about the care plan requirements and whether the seat belt was in use at the time of the fall, indicating a lack of adherence to the care plan and communication regarding the resident's safety needs.