Failure to Provide Adequate Supervision and Accident Prevention for Residents at Risk for Falls
Penalty
Summary
The facility failed to provide adequate supervision and care to prevent accidents for two residents identified as being at risk for falls. One resident with paraplegia, who was cognitively intact and dependent on two staff members for bed mobility, was left unattended at the bedside during care. The nursing assistant elevated the bed to waist height and did not return it to the lowest position. While the resident was positioned on their side for wound treatment, the staff member stepped away to call for a nurse, during which time the resident fell from the bed and required hospital evaluation and admission. Documentation indicated that the resident required two staff for repositioning and use of a turning sheet, but this protocol was not followed at the time of the incident. Another resident with spastic quadriplegia, who had a physician's order and care plan interventions for the bed to be kept in a low position with floor mats on both sides, was observed to have only one floor mat in place while in bed. Staff confirmed that a floor mat was missing from one side and acknowledged that both should have been present according to the care plan and physician's order. The DON was unable to provide evidence that the required safety interventions were in place for this resident at the time of observation.