Failure to Provide Adequate Supervision and Prevent Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for two residents, as evidenced by a review of facility policies, clinical records, and staff interviews. For one resident with severe cognitive impairment, atrial fibrillation, and dementia, the care plan required the use of leg rests and other safety features when being transported in a wheelchair. However, staff did not utilize the leg rests while pushing the resident, resulting in the resident abruptly slamming his feet down, grabbing the wall railing, and falling forward to the floor, sustaining a small injury to the forehead. The root cause was identified as poor safety awareness related to dementia and the failure of staff to use the required leg rests during transport. Another resident, who had diagnoses including debility, syncope, and a history of falls, was not properly assessed for transfer needs. The resident's baseline care plan did not specify the requirement for a mechanical lift for transfers, despite a physician's order indicating its necessity. After the order was discontinued, no further orders clarified the resident's transfer status. Subsequently, a CNA attempted to assist the resident into a wheelchair without a mechanical lift, and the resident slid out of the wheelchair onto the floor, with a towel in the seat contributing to the slide. The root cause was identified as the failure of staff to use a mechanical lift as required. Interviews with facility leadership confirmed that in both cases, staff did not follow established protocols and care plans designed to prevent falls. The incidents were attributed to staff not utilizing required safety equipment and not adhering to transfer procedures, resulting in falls and minor injuries to the residents involved.