Failure to Prevent Resident Neglect Resulting in Falls and Injuries
Penalty
Summary
The facility failed to protect two residents from neglect, resulting in harm. One resident, who was confused, required assistance with daily care, and had a history of falls, was care planned to wear hip protectors at all times. On the day of the incident, the resident refused to wear the hip protectors after a shower, and the nurse aide providing care did not notify other staff of this refusal. As a result, no alternative interventions were implemented, and the resident later fell, sustaining a left hip fracture. Documentation confirmed that the nurse aide did not re-approach the resident to apply the hip protectors and failed to follow the facility's policy for reporting refusals of care. Another resident, who had a history of stroke and was dependent on staff for activities of daily living, was being provided peri care by a nurse aide. During care, the aide rolled the resident away from herself, contrary to facility policy and standard of care, which requires rolling the resident toward the attendant when only one person is assisting. The resident rolled off the bed, hit her head on a trash can, and sustained a hematoma. The nurse aide admitted to rolling the resident away from herself and was unable to prevent the fall. Both nurse aides involved had received prior education on abuse and neglect. The facility's investigations substantiated neglect in both cases, as staff failed to follow established policies and procedures designed to prevent harm, resulting in significant injuries to the residents.